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CALIFORNIA, 

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UNIVCRSITY   OF    C4L1F0BNU     SAN    DIEGO   B 


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UNIVERSITY  O,^ 
LA  jOtL>.  CAL. 


SCIENCE  AND   EDUCATION 

A  SERIES   OF  VOLl/MEH  FOIt  THK  PROMOTION  OF 
SCIENTIFIC  RESEARCH  AND   EDUCATIONAL   FROGREHS 


Editkt>  15  y  J.  McKEEN  C  ATT  FA  A  j 


VOLUME  11  — MEDICAL  RESEARCH  AND  EDUCATION 


UNDER   THE   SAME  EDITORSHIP 


SCIENCE  AND  EDUCATION.  A  series  of  volumes  for 
the  promotion  of  scientific  research  and  educational 
progress. 

Volume  I.  The  Foundations  of  Science.  By  H. 
PoiNCARi^.  Containing  the  authorized  English 
translation  by  George  Bruce  Halsted  of  "Science 
and  Hypothesis,"  "The  Value  of  Science,"  and 
"Science  and  Method." 

Volume  II.  Medical  Research  and  Education.  By 
Richard  Mills  Pearce,  William  H.  Welch,  W.  H. 
Howell,  Franklin  P.  Mall,  Lewellys  F.  Barker, 
Charles  S.  Minot,  W.  B.  Cannon,  W.  T.  Council- 
man, Theobald  Smith,  G.  N.  Stewart,  C.  M.  Jack- 
son, E.  P.  Lyon,  James  B.  Herrick,  John  M.  Dod- 
son,  C.  R.  Bardeen,  W.  Ophiils.  S.  J.  Meltzer,  James 
Ewing,  W.  W.  Keen,  Henry  H.  Donaldson,  Christ- 
ian A.  Herter,  and  Henry  P.  Bowditch. 

Volume  III.  University  Control.  By  J.  McKeen 
Cattell  and  other  authors. 

AMERICAN  MEN  OF  SCIENCE.  A  Biographical 
Directory. 

SCIENCE.  A  weekly  journal  devoted  to  the  advancement 
of  science.  The  official  organ  of  the  American  Asso- 
ciation for  the  Advancement  of  Science. 

THE  POPULAR  SCIENCE  MONTHLY.  A  monthly 
magazine  devoted  to  the  diffusion  of  science. 

THE  AMERICAN  NATURALIST.  A  monthly  journal 
devoted  to  the  biological  sciences,  with  special  refer- 
ence to  the  factors  of  evolution. 


THE   SCIENCE   PRESS 

NEW  YORK  GARRISON,  N.  Y. 


MEDICAL  EESEAECH 

I  »  » 

AND  EDUCATION 


BY 

Richard  M.  Pearce,  The  University  of  Pennsylvania ;  William 
H.  Welch,  W.  H.  Howell,  Franklin  P.  Mall,  Lewellys  F. 
Barker,  The  Johns  Hopkins  University  ;  Charles  S.  Minot,  W.  B. 
Cannon,  W.  T.  Councilman,  Theobold  Smith,  Harvard  Uni- 
versity ;  G.N.  Stewart,  Western  Reserve  University ;  C.  M. 
Jackson,  E.  P.  Lyon,  University  of  Minnesota ;  James  B.  Her- 
RiCK,  Rush  Medical  College ;  John  M.  Dodson,  University  of 
Chicago ;  C.  R.  Bardeen,  University  of  Wisconsin ;  W.  OpHtJLS, 
Stanford  University  ;  S.  J.  Meltzer,  Rockefeller  Institute  for  Med- 
ical Research ;  James  Ewing,  Cornell  University  Medical  College ; 
W.  W.  Keen,  Jefferson  Medical  College ;  Henry  H.  Donaldson, 
Wistar  Institute  of  Anatomy ;  The  late  C.  A.  Herter,  Columbia 
University ;    The  late  Henry  P.  Bowditch,  Harvard  University. 


THE  SCIENCE  PRESS 
NEW  YORK  AND   GARRISON,  N.  Y. 

1913 


x)  ^-y. 


\ 


/\4-,'C^w: 


LIBRARY 
SCRIPPS     INSTITUTION 

OF    OCEANOGRAPHY 

UNIVERSITY    OF    CALIFORNIA 

LA  JOLLA,  CALIFORNIA 


\/  1 


Copyright,  1913 
By  The  Science  Press 


PRESS  OF 

THE  NEW  ERA  PRINTING  COMPANY 

LANCASTER.  PA. 


CONTENTS 


/> 


Eesearch  in  Medicine.    By  Eichard  M.  Pearce. 

Antiquity  to  1800;  The  Efforts  of  Isolated  Investigators. ...  1 

The  Development  of  Laboratories  for  the  Medical  Sciences. ...  16 

Pasteur  and  the  Era  of  Bacteriology 33 

Present-day  Methods  and  Problems 48 

Medical  Eesearch  in  American  Universities;  Present  Facilities, 

ISTeeds  and  Opportunities 68 

The  Experimental  Method :  Its  Influence  on  the  Teaching  of  Medi- 
cine.   By  Eichard  M.  Pearce 89 

Chance  and  the  Prepared  Mind.    By  Eichard  M.  Pearce 131 

The  Interdependence  of  Medicine  and  Other  Sciences  of  Nature. 
By  William  H.  Welch 143 

Medicine  and  the  University.    By  William  H.  Welch 165 

The  Eelation  of  the  Hospital  to  Medical  Education  and  Eesearch. 
By  William  H.  Welch 183 

The  Medical  School  as  Part  of  the  University.    By  W.  H.  Howell.  195 

Liberty  in  Medical  Education.    By  Franklin  P.  Mall 211 

Medicine  and  the  Universities.    By  Lewellys  P.  Barker 223 

Some  Tendencies  in  Medical  Education  in  the  United  States.    By 
Lewellys  F.  Barker 241 

Certain  Ideals  of  Medical  Education.    By  Charles  S.  Minot 279 

The  Career  of  the  Investigator.    By  W.  B.  Cannon 295 

Experiences  of  a  Medical  Teacher.    By  W.  T.  Councilman 305 

Medical  Eesearch :  Its  Place  in  the  University  Medical  School.    By 
Theobald  Smith 319 

The  Outlook  in  Medicine.    By  0.  N".  Stewart 337 

Problems,  Methods  and  Organization  of  Eesearch  with  Special  Eef- 
erence  to  Physiology.    By  G.  IsT,  Stewart 350 

On  the  Improvement  of  Medical  Teaching.    By  C.  M.  Jackson.  . .   367 

Equipment  and  Instruction  of  the  Laboratory  Years.     By  E.  P. 
Lyon   375 

The  Educational  Function  of  Hospitals  and  the  Hospital  Year.    By 
James  B.  Herrick 388 

V 


vi  CONTENTS 

The  Addition  of  a  Fifth  Year  to  the  Medical  Curriculum.    By  John 
M.  DoDSON   395 

Medicine  and  Sociology.    By  C.  E.  Baedeen 408 

The  Eelation  of  Eesearch  to  Teaching  in  Medical  Schools.    By  W. 
Ophuls   422 

The  Science  of  Clinical  Medicine.    By  S.  J.  Meltzer 428 

The  Public  and  the  Medical  Profession.    By  James  Ewing 440 

The  Duties  and  Eesponsibilities  of  Trustees  of  Public  Medical  In- 
stitutions.   By  W.  W.  Keen 457 

Eesearch  Foundations  and  their  Eelation  to  Medicine.    By  Henry 
H.  Donaldson 474 

Imagination  and  Idealism  in  the  Medical  Sciences.     By  the  late 
Christian  A.  Herter 487 

The    Medical    School   of   the    Future.      By   the   late   Henry   P. 
BOWDITCH  513 

Index 535 


RESEAECH   IN   MEDICINE 

The  Hitchcock  Lectures  at  the  University  of 

California* 

By  Eichard  M.  Pearce,  M.D., 
Professor  of  Research  Medicine,  University  op  Pennsylvania 


LECTUEE   I 


Antiquity  to  1800;  The  Efforts  of  Isolated  Investigators 

The  phrase  "  Eesearch  in  Medicine  "  will  naturally  arouse  different 
thoughts  and  associations  in  the  minds  of  different  groups  of  men. 
The  bacteriologist  will  be  reminded  of  Pasteur,  Koch,  Behring  and 
Elexner  and  the  triumphs  of  bacteriology  and  serum-therapy;  the  sur- 
geon, of  Lister  and  antisepsis,  of  anesthesia,  and  of  the  X-ray;  the 
physician  of  new  means  of  cure  and  of  diagnosis,  of  specific  sera  and 
vaccines,  of  the  electrocardiograph,  the  polygraph  and  other  compli- 
cated instruments  of  precision;  and  the  average  layman  of  a  confused 
and  confusing  welter  of  catchwords  and  slogans  for  popular  agitations 
vaguely  associated  with  antitoxins,  mosquitoes,  good  water  supply,  sew- 
age disposal,  lowered  infant  mortality  and  the  modern  treatment  of 
tuberculosis.  But  in  the  last  analysis  the  impressions  of  all  would  be  of 
progress  in  a  period  representing  a  little  more  than  half  of  the  past  cen- 
tury. This  period  is  indeed  the  golden  age  of  medical  progress  and  one 
to  which  the  historian  or  philosopher  must  give  his  best  attention  if  he 
is  to  interpret  properly  the  impulses  which  actuate  medical  research 
at  the  present  time.  That  the  earlier  history  of  medicine  is  over- 
shadowed by  the  rapid  progress  of  modern  discovery  as  represented  in 

*  A.  course  of  five  lectures  given  January  23  to  26,  1912,  and  printed  in 
The  Topiilar  Science  Monthly,  May  to  September,  1912.  The  Hitchcock  Lectures 
were  established  by  Mr.  Charles  M.  Hitchcock,  who  bequeathed  to  the  University 
of  California  an  endowment,  the  income  of  which  was  to  be  devoted  to  ' '  free 
lectures  upon  scientific  and  practical  subjects,  but  not  for  the  advantage  of  any 
religious  sect  nor  upon  political  subjects." 

2  1 


2  MEDICAL   BESEABCH   AND    EDUCATION 

bacteriology  is  in  the  nature  of  things.  But  it  should  not,  for  that 
reason,  be  forgotten  that  the  art  of  medicine  existed  before  this  period 
and  with  it  much  science.  The  pathologist,  on  second  thought,  reminds 
us  of  Morgagni  and  Eokitansky  and  the  beginnings  of  pathological 
anatomy;  the  physiologist  recalls  Harvey  and  Haller;  the  surgeon  men- 
tions Ambroise  Pare ;  the  anatomist,  after  recalling  many  worthies,  takes 
us  back  to  Vesalius,  to  Galen  and  finally  leaves  us  as  does  the  internist, 
with  Hippocrates,  400  years  before  Christ. 

With  this  stretch  of  time  and  with  these  widely  varying  aspects  of 
endeavor  one  must  deal  in  attempting  to  present  the  story  of  research 
in  medicine.  It  would  be  comparatively  simple  to  chronicle  the  ad- 
vance in  any  one  field,  as,  for  example,  surgery,  pathology  or  therapy; 
but  this  would,  I  fear,  be  less  interesting  and  certainly  not  enlighten- 
ing as  to  the  full  influence  of  research.  The  advantages  to  the  com- 
munity resulting  from  research  in  medicine  are  advantages  because  re- 
search has  done  away  with  conditions  which  were  disadvantageous  to 
the  health,  the  happiness  and  prosperity  of  the  community — in  short 
such  research  has  removed  the  impediments  to  a  higher,  happier  and 
more  prosperous  civilization.  It  is  necessary,  therefore,  in  order  to 
emphasize  the  importance  of  what  has  been  accomplished,  to  portray 
the  conditions  of  community  life  and  individual  hygiene,  of  medical 
practise  and  medical  thought,  and  of  science  and  philosophy  at  such 
periods  as  immediately  precede  definite  advances  in  medical  knowledge. 
The  first  of  these  lectures,  then,  bringing  the  story  down  to  the  begin- 
ning of  the  nineteenth  century,  will  be  presented  from  this  point  of 
view.  The  second  lecture  devoted  to  the  influence  of  physics  and  chem- 
istry, and  the  third  to  the  rise  of  bacteriology,  will  outline  the  develop- 
ment of  laboratory  methods  of  investigation,  the  story,  essentially,  of 
medicine  in  the  last  half  of  the  nineteenth  century.  The  fourth  lec- 
ture will  be  a  survey  of  present-day  methods  and  problems,  and  the 
fifth  lecture  will  be  a  discussion  of  the  position  of  medical  research  in 
America,  its  facilities,  needs  and  opportunities,  with  special  reference 
to  medical  research  as  a  function  of  the  university. 

Of  medicine  in  the  earliest  stages  of  its  development  we  have  no 
knowledge.  Not  until  we  arrive  at  a  period  of  civilization  as  highly  de- 
veloped as  that  of  the  Assyrians  and  Egyptians  do  we  find  references 
to  the  practise — the  studied  practise — of  medicine  as  a  healing  art. 
For  all  that  precedes  that  period  we  must  rely  on  analogy  with  med- 


EESEAECH    IN    MEDICINE  o 

ical  practises  among  the  aboriginal  races  to-day.  But  we  can,  neverthe- 
lesSj  safely  assume  that  the  healing  art  in  all  times,  no  matter  how 
simple  its  form,  was  the  practise  of  methods  having  for  their  object 
the  relief  of  pain  or  the  repair  of  injuries  caused  by  mechanical  means. 
Such  methods  must  have  been,  at  first,  instinctive  and  empiric,  or  the 
result  of  chance  observation.  Some  may,  indeed,  have  been  analogous 
to  the  methods  which  an  animal  adopts  to  cleanse  a  wound  or  protect 
an  injured  limb.  The  use  of  irritants,  of  emollients  and  of  scarification, 
the  binding  of  wounds,  the  mechanical  support  of  a  fracture  and  assist- 
ance in  childbirth  are  primitive  practises  doubtless  resulting  from 
chance  observation  or  experience.  It  is  readily  conceivable  that  the  use 
of  stone  tools  and  weapons  in  hunting  and  in  war  may  have  originated 
the  idea  of  intervention  by  operation;  and  that  surgical  dexterity  may 
have  increased  proportionately  to  the  improvement  of  weapons  in  the 
bronze  age.  Likewise  it  must  be  assumed  that  chance  experience  led 
to  a  knowledge  of  the  action  of  the  vegetable  and  mineral  substances 
of  the  early  materia  medica.  But  of  these  beginnings  we  have  no  his- 
torical knowledge. 

Our  first  authentic  knowledge  of  medicine,  fragmentary  though  it 
is,  is  obtained  from  the  cuneiform  inscriptions  which  record  the  Baby- 
Ionic- Assyrian  civilization.  These  records  are  of  a  medicine  controlled 
by  the  priesthood,  closely  linked  to  astrology  and  characterized  by  a 
belief  in  the  influence  of  metaphysical  forces,  gods  and  demons.  They 
do,  however,  contain  references  to  the  use  of  the  knife  in  surgery,  the 
healing  of  fractures  and  the  internal  administration  of  herbs,  but  all 
essential  therapy  is  obscured  by  mysticism,  ritual  observances  and 
magical  formula.  From  the  point  of  view  of  diagnosis,  it  is  of  interest 
that  these  records  refer  to  the  inspection  of  the  urine  and  blood  and  to 
the  collection  of  a  series  of  observations  upon  disease,  what  we  would 
now  call  the  "  clinical  history  "  or  record  of  a  patient.  These,  however, 
were  taken,  not  as  to-day  to  aid  in  the  diagnosis,  but  had  the  value  of 
omens  to  aid  the  priest  in  his  prophecy  as  to  the  outcome  of  the  illness, 
or  as  we  would  say  to  aid  prognosis.  Such  records  were  of  little  value, 
for  without  a  knowledge  of  pathology — that  is,  of  the  underlying  ana- 
tomical changes  responsible  for  the  symptoms — they  were  on  the  same 
level  as  astrological  speculation  and  the  interpretation  of  dreams.  In- 
ferences were  not  drawn  from  the  empirical  facts  of  clinical  observa- 
tions, but  all  observations  were  interpreted  in  the  light  of  the  super- 


4  MEDICAL   BE  SEARCH   AND   EDUCATION 

natural,  the  ritualistic  and  the  magical.  This  veil  we  find  over  all  an- 
cient medicine. 

Egyptian  medicine  of  a  period  2,000  B.C.  was  much  the  same  as  the 
Assyrian,  but  the  priestly  science,  as  taught  in  the  schools  of  the 
temples,  developed  a  considerable  knowledge  of  botany  and  zoology, 
without,  however,  an  insight  into  the  structure  and  functions  of  the 
human  body.  An  extensive  materia  medica  allowed  the  use  of  medi- 
cines as  draughts,  electuaries,  gargles,  snuffs,  inhalations,  salves, 
plasters,  poultices,  injections,  suppositories,  enemata  and  fumigations. 
As  to  general  surgery,  there  is  no  evidence,  aside  from  circumcision 
and  castration,  of  operations  other  than  those  for  the  removal  of  surface 
tumors.  Yet  ophthalmology,  otology  and  dentistry  were  known  and 
practised  as  specialties.  Obstetrics,  on  the  other  hand,  does  not  ap- 
pear to  have  been  of  interest  to  the  physician.  The  hygiene  of  the 
Egyptians  ranked  higher  than  their  therapeutics  and  included  definite 
l-ules  concerning  meat  inspection,  bathing,  clothing,  diet,  care  of  the 
dwelling  and  of  infants.  Indeed  there  is  much  ground  for  the  belief 
that  much  of  our  modern  hygiene  can  be  traced  back  through  Greek 
and  Hebrew  to  the  pioneer  work  of  the  ancient  Egyptians. 

Persian  medicine  is  of  little  moment  and  differs  but  slightly  from 
that  of  other  ancient  peoples  in  its  religious-hygienic  measures.  One 
phase  of  religious  belief  was  disastrous  for  the  development  of  even 
simple  empiricism — the  belief  that  the  dead  and  the  diseased  were  un- 
clean. Such  a  view  naturally  made  impossible  the  study  of  anatomy 
and  diagnosis.  The  sick,  as  unclean,  were  isolated,  washed  and  purified 
— a  procedure  which  in  our  time  we  associate  with  good  hygiene  and 
the  care  of  those  suffering  with  contagious  diseases ;  with  the  Persians, 
however,  it  was  purely  a  religious  form  based  on  a  belief  in  demons. 

After  the  priestly  hygiene  of  the  Egyptians  and  Persians  comes 
naturally,  and  probably  sequentially,  the  social  hygiene  of  the  Old 
Testament.  I  need  only  remind  you  of  the  Mosaic  laws,  rational  even 
in  the  light  of  modern  science. 

From  the  literature  of  antiquity  much  else  might  be  cited  to  show 
the  state  of  medicine  among  ancient  peoples,  the  influence  of  religion, 
of  primitive  superstition  and  mysticism,  all  of  which,  however  well-in- 
tentioned, prevented  or  obscured  exact  observation  and  deduction. 
The  development  of  knowledge  by  observation  and  critical  argument 
came  slowly,  and  was  possible  only  when  the  priest  was  no  longer  the 


BESEABCH    IN    MEDICINE  5 

physician.     This  great  advance  we  associate  with  the  period  of  Greek 
civilization  and  the  name  of  Hippocrates. 

Hippocrates  may  be  considered  in  many  ways,  as  physician,  surgeon, 
philosopher  and  medical  historian,  but  to  one  interested  in  the  begin- 
nings of  research  in  medicine  he  is  of  importance  as  the  first  to  record 
results  based  on  observation,  experiment  and  deduction,  the  tripod  of 
the  method  of  science.  As  a  result,  although  much  of  his  theory  has 
been  discarded,  many  of  his  procedures  based  on  exact  observation  still 
stand  the  test  of  time  and  in  many  instances  form  the  basis  of  modern 
methods.  His  age  (470-361  B.C.)  was  the  age  of  Pericles;  contempo- 
rary with  him,  Thucydides  wrote  history,  Phidias  carved  statues, 
Democritus  originated  his  atomistic  theory  of  the  universe,  and  Soc- 
rates talked  "  human  affairs  "  and  "  practical  reason."  That  these  men 
were  real  to  one  another  is  shown  by  the  fact  that  Hippocrates  was  re- 
quested to  declare  Democritus  insane  and  that  Pericles  died  (429  B.C.) 
of  the  great  plague  which  Hippocrates  attempted  to  combat. 

From  this  correlation  of  names  it  is  evident  that  medicine  shared  in 
the  general  growth  of  Greek  culture,  and  there  is  every  evidence  that 
Hippocrates  was  as  great  a  representative  of  Greek  intellect  as  were  his 
contemporaries.  Greece  was  at  the  height  of  its  brilliant  progress;  it 
was,  for  the  time  being,  the  political,  commercial,  intellectual,  scien- 
tific and  artistic  center  of  the  universe.  But  among  the  Greeks  the 
priests  were  not,  fortunately  for  medicine,  political  or  intellectual  lead- 
ers; leadership  was  possessed  first  by  the  poets  and  later  by  the  phi- 
losophers, and,  under  such  circumstances,  Greek  medicine,  freed  of  re- 
ligious influence  and  fostered  by  philosophy,  took  a  substantial  form, 
and,  though  it  contained  much  of  generalized  speculation,  it  had  the 
solid  foundation  of  unbiased  observation.  The  former  has  perished 
under  the  influence  of  time  and  progress;  the  latter,  resting  on  actual 
experience  and  genuine  biological  knowledge,  remains.  Of  the  meth- 
ods of  Hippocrates  some  idea  may  be  obtained  from  the  fact  that  he  is 
responsible  for  the  very  term  "  hypothesis,"  which,  in  its  scientific  ap- 
plication, he  invented. 

Some  of  the  experiments  of  the  Hippocratic  schools  may  be  con- 
sidered as  the  first  in  the  field  of  experimental  physiology,  as  for 
example,  the  feeding  at  the  same  time  of  different  kinds  of  food  and 
the  study,  after  induced  vomiting,  of  the  stage  of  digestion  of  each. 
It  is,  however,  in  the  field  of  clinical  observation  that  Hippocrates 


6  MEDICAL   BESEABCH   AND   EDUCATION 

excelled.  His  inferences  were  frequently  wrong,  but  his  descriptions 
of  the  symptoms  of  a  disease,  as  an  aid  to  diagnosis  and  prognosis, 
were  at  once  picturesque  and  accurate.  How  accurate  and  vivid  they 
were  may  be  seen  from  the  fact  that  the  characteristic  signs  of  impend- 
ing death  are  still  known  as  the  "  facies  Hippocrates."  This  exercise 
of  minute  observation  and  accurate  interpretation  of  every  symptom — 
the  method  of  clinical  medicine — which  has  influenced  medicine  in  all 
succeeding  ages,  was  the  beginning  of  the  study  of  what  we  now  term 
the  "  natural  history  of  disease."  In  therapy  Hippocrates  recognized 
the  natural  tendency  to  health  {vis  medicatrix  natures)  and  this  prin- 
ciple influenced  all  his  therapeutic  efforts.  In  addition  to  this  sub- 
stantial service  to  medicine  we  owe  him  certain  idealistic  influences  as 
shown  in  the  Hippocratic  oath  and  in  his  constant  desire  to  place  all 
knowledge  freely  and  fully  before  the  profession  at  large. 

Certainly  medicine  under  Hippocrates,  as  contrasted  with  that  of 
the  preceding  ages,  was  magnificent,  and  it  is  not  surprising  that  after 
his  death,  he  was  deified.  To  us  he  represents  the  beginnings  of  an 
exact  medicine,  and  his  influence  is  seen  in  many  of  the  theories, 
methods  and  ideals  of  modern  practise.  Hippocratic  medicine,  Hip- 
pocratic doctrine,  Hippocratic  oath,  are  current  phrases,  and  the  admoni- 
tion "  Back  to  Hippocrates  "  is  an  admonition  to  beware  of  theory  and 
seek  the  solid  ground  of  observation  and  experiment. 

Between  Hippocrates  and  Galen  lie  nearly  five  hundred  years  with- 
out progress  in  medicine,  except  as  the  brilliant  Alexandrian  school, 
sheltering  Euclid,  Archimedes  and  Ptolemy  developed,  under  Heroph- 
ilus  and  Erasistratus,  a  school  of  anatomy  (ca.  300  B.C.)  which  estab- 
lished many  new  anatomical  facts.  But  as  Neuburger  states  in  his 
discussion  of  early  medical  theories,  "  Collection  and  observation  of 
facts  constitute  the  first  step  in  science,  but  not  science  itself."  The 
observation  of  anatomical  facts  during  these  centuries  is  naturally  of 
some  importance  in  connection  with  the  growth  of  anatomy,  but 
unfortunately  of  no  importance  as  regards  the  influence  of  those  facts 
on  medical  theory,  for  physiology  remained  a  field  for  speculation  while 
the  facts  gained  from  anatomy  were  used  only  to  strengthen  the  older 
speculation  and  dogmatism,  and  to  rehabilitate  discarded  doctrines. 
To  the  Alexandrian  school  and  to  Galen,  however,  must  be  given  the 
credit  of  a  careful  study  of  anatomy  by  dissection,  and  this  honor  is  the 
more  deserved  because,  from  Galen  to  Vesalius — a  stretch  of  nearly 
fourteen  hundred  years — knowledge  of  anatomy  was  not  advanced. 


RESEABCE    IN    MEDICINE  7 

Galen  (131-301  a.d.),  a  Greek,  working  in  Eome,  followed  the 
traditions  of  the  Alexandrian  school  in  which  he  had  been  educated. 
He  dissected  freely  a  variety  of  animals,  including,  it  is  recorded,  an 
elephant.  It  is,  however,  as  an  experimental  physiologist  that  he 
brought  new  light  to  medicine.  He  supported  the  statements  of  the 
Alexandrian  school,  that  nerves  had  motor  and  sensory  functions,  elab- 
orated the  theory  of  the  control  of  muscles  by  nerves,  and  of  the  brain 
as  the  center  of  the  nervous  system,  and,  more  important  still,  sup- 
ported these  convictions  by  well-planned  ingenious  experiments.  His 
experiments  on  the  brain  and  cord  constitute  the  first  experimental 
study  of  the  cause  of  paralysis,  and  he  thereby  became  cognizant  of  the 
fact  that  injury  to  one  side  of  the  brain  affects  the  opposite  side  of  the 
body.  He  established,  again  by  experiment,  that  urine  is  secreted  by 
the  kidneys,  and  propounded  the  theory  that  the  blood  goes  to  the  kid- 
neys in  order  that  the  watery  part  may  be  filtered  off.  He  studied  the 
heart  and  its  movements,  recognized  the  fetal  nature  of  the  foramen 
ovale  and  the  ductus  arteriosus,  wrote  of  aneurism  and  practised  the 
ligation  of  arteries. 

Galen  is  the  link  between  Hippocrates  and  Alexandrian  anatomy, 
on  the  one  hand,  and  Vesalius  and  Harvey,  on  the  other. 

With  his  death  and  the  passing  of  his  immediate  successors  progress  lan- 
guished and  expired,  for  the  ancient  world  was  dying  and  was  bearing  down 
with  it  the  humaner  arts.  .  .  .  For  generations  it  seemed  that  the  church  alone 
had  survived  .  .  .  cherishing  ignorantly  often,  but  jealously  and  fiercely,  the 
records  of  a  past  science.     (Mumford.) 

The  intellectual  world  of  Eome,  Alexandria  and  Constantinople  was 
busied  with  theological  controversies.  The  church  became  the  arbiter 
of  all  knowledge  and  demanded  that  all  science  must  conform  to  the 
Scriptures.  Moral  and  intellectual  progress  became  impossible.  The 
political  world  survived  the  invasion  of  the  barbarians,  but  the  intel- 
lectual world  was  dying  of  dogma.  For  hundreds  of  years  it  was  "  first 
the  soldier;  second  the  priest;  third  the  lawyer;  fourth  the  merchant; 
fifth  the  physician ;  and  then  after  a  long  interval  the  surgeon,  ranking 
with  the  humblest  of  craftsmen."      (Mumford.) 

Nearly  fourteen  centuries  pass  after  Galen  before  we  can  again  take 
up  the  thread  of  progress.  In  these  centuries — lost  to  science  gen- 
erally— the  history  of  medicine  shows  but  one  isolated  period  of  effort 
worthy  of  mention.  This  is  that  period  represented  by  the  Arabian 
school  founded  after  the  Mahommedan  conquest  and  at  its  best  from 


8  MEDICAL   BESEABCH   AND    EDUCATION 

the  ninth  to  twelfth  centuries.  This  school  represents  no  progress  in 
anatomy,  physiology  or  the  general  theory  of  medicine  (which  is  to  be 
explained  by  the  fact  that  the  religion  of  the  Mussulman  considers 
contact  with  a  corpse  sacrilege  and  thus  debars  dissection),  but  the 
Arabs  had  an  insight  into  chemistry,  and,  though  they  pursued  their 
researches  in  the  interests  of  alchemy  and  in  the  hope  of  finding  the 
"  elixir  of  life  "  or  means  of  transmuting  metals,  they  made,  neverthe- 
less, valuable  chemical  discoveries  and  in  this  way  aided  the  art  of 
pharmacy. 

"We  therefore  enter  the  sixteenth  century  of  the  christian  era  with 
little  or  nothing  added  during  2,000  years  to  Hippocrates's  methods  of 
exact  observation  in  clinical  medicine  and  surgery,  with  no  decisive 
contribution  to  anatomy  or  experimental  physiology  for  1,300  years 
and  with  the  beginnings  of  chemistry  as  applied  to  medicine  and  phar- 
macy removed  by  600  years. 

But  despite  this  absence  of  real  progress,  a  thin  thread  of  learning 
and  practise  connected  the  medicine  of  Galen  with  the  dawn  of  science 
in  the  middle  ages.  This  is  evident  in  the  story  of  medicine  in  the 
monasteries  and  in  the  schools  at  Salerno  and  Montpellier  in  the  twelfth 
century,  but  it  is  a  medicine  of  the  Eoman  period  tinctured  with  magic 
and  superstition  and  with  no  advance  in  theory  or  practise  and  certainly 
no  increase  in  science. 

The  medicine  associated  with  the  revival  of  learning  had  its  begin- 
nings in  the  translation  of  Greek  treatises  on  medicine  through  the 
Arabic;  and  in  the  early  universities,  especially  those  of  Padua  and 
Bologna  and  this  revival  of  the  exact  methods  of  Hippocrates  and 
Galen,  gave  to  medicine  a  basis  more  substantial  than  the  traditions  of 
monastic  medicine  which  had  been  perpetuated  through  ten  centuries, 
and  upon  which  were  founded  those  widely  scattered,  but  epoch-making 
advances  which  medicine  reckons  as  its  share  in  the  general  revival  of 
literature,  art  and  the  sciences.  With  the  name  of  Luther,  Michael 
Angelo,  Eaphael,  Titian,  Copernicus,  Columbus  and  Galileo  we  place 
those  of  Vesalius,  Pare  and  Harvey.  These  names  represent  the  period 
of  the  Eenaissance,  to  which  we  look  back  with  pride  and  satisfaction, 
but  seldom  with  a  thought  of  the  conditions  of  home  and  community 
life.  We  are  concerned  usually  with  its  deeds  and  achievements  rather 
than  with  its  social  and  hygiene  conditions.  But  it  is  to  the  latter  that 
I  wish  here  briefly  to  direct  attention. 


BESEAECE   IN    MEDICINE  9 

The  homes  and  habits  of  the  people  were  filthy.  As  late  as  the  sixteenth 
century  in  England,  the  streets  of  the  populous  cities  were  paved  with  straw  and 
rushes,  which  soon  broke  up  into  powdered  dust.  Householders  swept  the  filth 
of  their  apartments  into  the  streets,  and  threw  garbage  there  also,  where,  with 
the  ground  of  rush  and  straw,  a  most  intolerably  filthy  condition  was  produced, 
which  rain  modified,  but  did  not  remove.  Moreover,  people  seldom  bathed  their 
bodies  or  washed  their  clothes.  Besides,  the  food  they  ate  contributed  to  disease. 
They  lived  chiefly  on  salt  fish  and  flesh,  with  a  modicum  of  stale  vegetables. 
The  domestic  animals,  the  source  of  their  meat,  were  herded  in  enclosures  of  the 
worst  imaginable  filth.  Mutton  was  the  chief  flesh  food  of  the  people,  but  their 
flocks  in  cold  season  were  herded  in  basements,  partly  underground,  places  with- 
out light  and  air  except  such  as  gained  admittance  from  the  door.  Milch  cows 
were  confined  to  these  places  also.  The  source  of  the  food  supply  was,  therefore, 
foul.  .  .  .  Places  of  public  resort  were  without  means  of  ventilation.  The  air 
of  the  churches  was  death-dealing,  and  made  tolerable  only  by  the  fumes  of 
incense.  (Gorton.)  Personal  cleanliness  was  unknovni;  great  officers  of  state, 
even  dignitaries  as  high  as  the  Archbishop  of  Canterbury,  swarmed  with  vermin; 
such  it  is  related  was  the  condition  of  Thomas  a'  Becket,  the  antagonist  of  an 
English  king.  To  conceal  personal  impurity,  perfumes  were  necessarily  and 
profusely  used.  The  citizen  clothed  himself  in  leather,  a  garment,  which,  with 
its  ever-accumulating  impurity,  might  last  for  many  years.  .  .  .  After  night-fall 
the  chamber  shutters  were  thrown  open,  and  slops  unceremoniously  emptied 
down.     (Draper.)^ 

*  The  original  upon  which  these  statements  are  based  I  have  been  unable  to 
obtain.  Gorton's  statement  is  evidently  at  second  hand.  C.  Creighton  in  his 
"History  of  Epidemics  in  Great  Britain"  doubts  the  accuracy  of  the  sweeping 
charges  ' '  of  neglect  of  public  hygiene ' '  and  ' '  of  lack  of  rudimentary  instincts 
of  cleanliness"  in  Plantagenet  and  Tudor  times,  but  as  careful  a  writer  as 
F.  Harrison  gives  in  "The  Meaning  of  History"  the  following  summary  of 
personal  and  community  hygiene  in  the  Middle  Ages: 

' '  The  old  Greek  and  Eoman  religion  of  external  cleanness  was  turned  into 
a  sin.  The  outward  and  visible  sign  of  sanctity  now  was  to  be  unclean.  No  one 
was  clean;  but  the  devout  Christian  was  unutterably  foul.  The  tone  of  the 
Middle  Ages  in  the  matter  of  dirt  was  a  form  of  mental  disease.  Cooped  up  in 
castles  and  walled  cities,  with  narrow  courts  and  sunless  alleys,  they  would  pass 
day  and  night  in  the  same  clothes,  within  the  same  airless,  gloomy,  windowless 
and  pestiferous  chambers ;  they  would  go  to  bed  without  night  clothes,  and  sleep 
under  uncleansed  sheep-skins  and  frieze  rugs;  they  would  wear  the  same  leather, 
fur  and  woolen  garments  for  a  lifetime,  and  even  for  successive  generations ;  they 
ate  their  meals  without  forks,  and  covered  up  the  orts  with  rushes;  they  flung 
their  refuse  out  of  the  window  into  the  street  or  piled  it  up  in  the  back-yard; 
the  streets  were  narrow,  unpaved,  crooked  lanes  through  which,  under  the  very 
palace  turrets,  men  and  beasts  tramped  knee-deep  in  noisome  mire.  This  was  at 
intervals  varied  with  fetid  rivulets  and  open  cesspools ;  every  church  was  crammed 
with  rotting  corpses  and  surrounded  with  graveyards,  sodden  with  cadaveric 
liquids,  and  strewn  with  disinterred  bones.  Round  these  charnel  houses  and 
pestiferous  churches  were  piled  old  decaying  wooden  houses,  their  sole  air  being 
these  deadly  exhalations,  and  their  sole  water  supply  being  these  polluted  streams 
or  wells  dug  in  this  reeking  soil.    Even  in  the  palaces  and  castles  of  the  rich  the 


10  MEDICAL  EESEABCH  AND  MEDICAL  EDUCATION 

From  the  fourteenth  to  the  sixteenth  century  plagues  were  frequent 
and  attended  with  great  mortality.  Among  the  plagues  known  by 
various  names  as  the  "  sweating  sickness/'  "  black  death,"  etc.,  we  are 
able  to  distinguish  bubonic  plague,  typhus  and  small-pox.  Likewise 
syphilis  had  been  on  the  increase  since  the  fifteenth  century,  and  pre- 
sented a  peculiar  malignancy,  and,  like  small-pox,  attacked  high  and 
low  alike.  The  causes  and  origin  of  these  plagues  are  not  difficult  to 
find.  Except  for  the  Cloaca  Maxima  at  Eome  not  a  sewer  of  any  con- 
sequence existed  in  Europe;  drainage  was  inadequate,  the  streets  were 
unpaved,  and  public  baths  or  other  facilities  for  bathing  were  unknown. 
Of  sanitation  no  knowledge  was  at  hand.  The  dead,  including  the 
victims  of  various  plagues,  were  buried  hastily — instead  of  being  burned 
— and  usually  in  shallow  ditches,  thus  allowing  presumably  an  easy 
pollution  of  water  supplies.  As  to  this,  under  ordinary  circumstances 
no  precautions  were  taken  to  keep  the  water  supplies  free  from  fecal 
and  other  contaminations.  Doubtless,  taxes  on  bread  and  window 
panes  were  responsible  in  no  small  part  for  that  diminished  resistance 
which  invites  infection.  Against  the  spread  of  plagues  the  physicians 
were  helpless.  The  College  of  Physicians  at  Paris  in  the  fifteenth  cen- 
tury at  the  time  of  the  "  sweating  plague,"  were,  after  mature  consid- 
eration, "  of  the  opinion,  that  the  constellations,  with  the  aid  of  nature, 
strive,  by  virtue  of  their  divine  might,  to  protect  and  heal  the  human 
race."  This  state  of  mind  does  not  seem  so  surprising  when  we  recall 
that  Eoger  Bacon,  "  the  truest  philosopher  of  the  Middle  Ages,"  still 
sought,  in  the  thirteenth  century,  the  philosopher's  stone  and  the  elixir 
of  life,  "  The  Eoyal  Touch "  was  still  a  favorite  cure  for  scrofula 
("The  Kings  of  Evil")  and  various  other  ills,  and  indeed  persisted 
into  the  time  of  Queen  Elizabeth.  From  "  The  Anatomy  of  Melan- 
choly" (1621)  we  have  it  that  "there  be  many  mountebanks,  quack- 
salves  and  empiricks,  in  every  street  almost,  and  in  every  village." 

same  bestial  habits  prevailed.  Prisoners  rotted  in  noisome  dungeons  under  the 
banqueting  hall;  corpses  were  buried  under  the  floor  of  the  private  chapel; 
scores  of  soldiers  and  attendants  slept  in  gangs  for  months  together  in  the  same 
hall  or  guard-room  vehere  they  ate  and  drank,  played  and  fought.  It  is  one  of 
those  problems  which  still  remain  for  historians  to  solve — how  the  race  ever 
survived  the  insanitary  conditions  of  the  Middle  Ages,  and  still  more  how  it  was 
ever  continued — what  was  the  normal  death-rate  and  the  normal  birth-rate  of 
cities?  The  towns  were  no  doubt  maintained  by  immigration,  and  the  rural 
labourer  had  the  best  chance  of  life,  if  he  could  manage  to  escape  death  by 
violence  or  famine." 


EESEAECE    IN   MEDICINE  11 

Shall  Tve,  then,  wonder  that,  in  the  famine  of  1030,  human  flesh  was  cooked 
and  sold;  or  that,  in  that  of  1258,  fifteen  thousand  persons  died  of  hunger  in 
London?  Shall  we  wonder  that,  in  some  of  the  invasions  of  the  plague,  the 
deaths  were  so  frightfully  numerous  that  the  living  could  hardly  bury  the  dead? 
By  that  of  1348,  which  came  from  the  east  along  the  lines  of  commercial  travel 
and  spread  all  over  Europe,  one  third  of  the  population  of  France  was  destroyed. 
(Draper.) 

Also,  the  condition  of  the  insane  was  pitiable;  until  well  into  the 
eighteenth  century  they  were  imprisoned,  chained  and  treated  as  wild 
beasts. 

Eational  therapy  did  not  exist,  though  it  is  interesting  to  note  that 
several  important  empiric  specifics  came  gradually  into  general  use,  as 
mercury  and  sulphur  introduced  in  1510  by  Paracelsus,  sometimes 
termed  "  charlatan  and  bombast " ;  after  Harvey's  time,  Dover's  powder 
(Pulvis  IpecacuanhcB  Comp.)  through  Captain  Dover,  physician  and 
buccaneer;  and  Cinchona  (quinine)  through  the  Countess  of  Cinchon, 
wife  of  the  "Viceroy  of  Peru,  who  brought  it  to  the  attention  (1638)  of 
the  Jesuit  priests,  hence  the  name,  Jesuit's  bark.  Truly,  empirical 
therapy  made  progress  by  curious  routes. 

Civil  surgery  was  in  a  chaotic  state,  the  barber  surgeon  contended 
with  the  surgeon  proper  or  "  surgeon  of  the  long  robe  "  in  the  fields  of 
minor  surgery  and  both  ranked  far  below  the  physician.  In  fact,  sur- 
gery was  largely  abandoned  to  a  class  of  ignorant  barbers,  bathers  and 
bone-setters.  Many  operators  were  itinerant,  going  from  city  to  city 
and  frequently  limiting  their  work  to  one  or  two  kinds  of  operation, 
as  that  for  cataract,  or  stone,  or  hernia.  Military  surgery  without 
anesthesia  or  antisepsis  was  a  horror  of  rough  and  ready  emergency 
operations  with  boiling  oil  or  heated  iron  as  styptic  and  cautery,  a 
torture  beyond  imagination.  Indeed,  to  get  an  idea  of  the  horrors  of 
surgery  in  the  lazaretto  of  the  battle  field  even  down  to  the  year  1812, 
the  date  of  Napoleon's  descent  upon  Moscow,  one  needs  but  to  read 
Tolstoy's  work  "  War  and  Peace." 

Thus  we  find  the  stage  set  for  Vesalius  and  Pare,  who  with  Hunter, 
though  he  entered  somewhat  later,  laid  the  foundation,  which,  when 
anesthesia  and  antisepsis  were  added  in  the  nineteenth  century,  gave 
surgery  its  right  to  claim  a  scientific  basis.  Vesalius,  occupying  a  chair 
of  surgery  at  Padua,  developed  anatomy  as  an  exact  observational  sci- 
ence ;  indeed  he  may  be  considered  as  the  founder  of  modern  anatomical 
research.     This  was  his  great  work ;  this  and  his  influence  in  weakening 


12  MEDICAL   HESEABCH   AND   EDUCATION 

the  old  speculative  medicine  and  in  establishing  the  principles  of  the 
scientific  method.  It  was  not  an  immediate  influence,  for  upon  the 
publication  (1543)  of  his  Fabrica  Humani  Corporis  "the  wrath  of 
intrenched  conservatism  descended  upon  him  "  and  he  was  forced  to 
leave  Padua,  but  his  work  was  not  in  vain,  for  it  hastened  the  develop- 
ment of  surgical  science  and  gave  to  anatomy  the  impetus  necessary  for 
its  development  as  an  observational  science. 

Ambroise  Pare  (1510-1590)  began  life  as  an  humble  barber-surgeon,  and 
ended  as  the  greatest  surgical  authority  of  Europe  and  the  best  loved  man  in 
France.     (Mumford.) 

Why  the  greatest  authority?  Because  he  went  through  the  world 
with  his  eyes  open.  Why  the  best  beloved?  Because  of  his  own 
unaided  efforts  he  did  away  with  more  actual  pain  than  has  perhaps 
any  other  single  individual  except  the  discoverer  of  anesthesia.  His 
methods  were  those  of  the  practical  clinician — observation  as  the  basis 
of  deduction  unhampered  by  tradition.  The  story  is  told  that  Pare  in 
his  first  military  campaign  followed  the  old  custom  which  prescribed 
the  use  of  boiling  oil  for  all  wounds.  But  after  one  severe  engagement 
the  oil  gave  out  and  he  used,  fearful  of  the  consequences,  a  simple  oint- 
ment. To  his  surprise  he  found  that  the  wounds  so  treated  healed  more 
rapidly  than  under  the  old  treatment.  On  this  basis  of  simple  observa- 
tion and  sound  reasoning,  he  combated,  against  great  opposition,  the 
old  treatment  and  established  simple  rules  for  the  care  of  wounds.  So 
also  was  it  with  the  ligation  of  vessels  after  amputation.  The  custom 
had  been  to  cauterize  with  the  red-hot  iron,  the  effect  of  which  both 
physically  and  mentally  it  is  not  difficult  to  imagine.  Pare  reasoned 
that  as  ligation  of  veins  and  arteries  in  simple  wounds  was  possible,  it 
was  possible  also  at  amputation,  and  at  the  first  opportunity  he  demon- 
strated the  correctness  of  his  views.  So  by  doing  away  with  boiling  oil 
and  the  heated  iron  he  ranks  among  the  greatest  of  humanitarians  and, 
by  establishing  rational  procedures  for  the  treatment  of  wounds  and 
for  the  ligation  of  vessels,  as  one  of  the  greatest  of  surgeons. 

Here  it  is  well  to  depart  from  the  chronological  order  and  discuss 
John  Hunter  and  his  work  and  thus  bring  the  advance  in  surgery  to 
the  year  1800.  Between  Pare  and  Hunter  surgery  was  influenced  by 
Haller  and  Harvey,  but  both  these  must  be  treated  in  detail  in  a  con- 
sideration of  other  lines  of  activity.  Suflfice  it  to  point  out  here  that 
Harvey's  work  on  the  circulation  of  the  blood  and  Malpighi's  discovery 


EESEAECH    IN   MEDICINE  13 

of  capillary  circulation  advanced  surgery  enormously  by  clearing  up 
for  the  surgeon  the  mysteries  of  the  blood-vascular  system.  The  dread 
of  hemorrhage  had  previously  deterred  surgeons  from  all  operations 
except  those  of  dire  necessity  or  those  in  which  the  operation  was  in  a 
gangrenous  tissue.  With  this  mystery  of  hemorrhage  solved,  the  sur- 
geon boldly  ventured  into  new  territory  and  rapidly  extended  the  possi- 
bilities of  his  art. 

John  Hunter,  pathologist,  physiologist  and  surgeon,  was  active  in 
the  latter  part  of  the  eighteenth  century.  He  worked  in  anatomy,  com- 
parative anatom}^,  physiology  and  surgery;  essentially  a  laboratory 
investigator,  "  content ''  it  is  said  "  with  four  hours  of  sleep,  scanty 
rations  and  little  play."  (Mumford.)  Many  were  his  contributions 
to  anatomy,  but  his  work  on  coagulation  of  the  blood,  inflammation  and 
the  repair  of  wounds,  and,  above  all,  the  demonstration,  that  after 
ligation  of  vessels  there  occurs  the  establishment  of  a  collateral  circula- 
tion by  anastomosis,  were  of  the  utmost  importance  to  surgery.  This 
latter,  the  basis  of  his  famous  operation  for  aneurism,  was  the  result  of 
a  study  of  the  growth  of  deer's  antlers,  in  the  course  of  which  he  tied 
one  of  the  carotid  arteries.  To  his  surprise  the  cold  antler  of  the 
ligated  side,  after  two  weeks,  became  warm.  Dissection  demonstrated 
that  the  ligature  had  not  slipped,  and  on  the  basis  of  this  observation  he 
established  those  principles  concerning  the  ligation  of  vessels  in  con- 
tinuity so  important  in  modern  surgery.  He  also  presented  the  first 
satisfactory  explanation  of  inflammatory  and  thrombotic  diseases  of 
veins  and  contributed  to  the  knowledge  of  gunshot  wounds  and  of 
many  other  phases  of  medical  science;  but  his  great  influence  was  the 
impetus  which  he  gave  to  proper  scientific  research  in  medicine  as  well 
as  surgery,  in  pathology  as  well  as  physiology. 

To  Hunter,  the  nineteenth  century  English  school  of  surgery  owes 
its  fame,  and  in  his  honor  the  Eoyal  College  of  Surgeons  established  the 
annual  Hunterian  Oration.  After  Hunter,  and  largely  due  to  his 
influence,  surgery  advanced  surely,  though  slowly,  but  without  momen- 
tous discoveries  until  the  advent  of  anesthesia  and  asepsis  in  the  middle 
of  the  nineteenth  century.  "We  may  therefore  leave  surgery  and  turn 
to  Harvey  and  events  in  physiology  prior  to  1800, 

Harvey  was  of  the  Elizabethan  period,  a  contemporary  of  Shake- 
speare, Milton,  Dryden,  Bacon,  Descartes  and  Kepler.  He  studied  at 
Cambridge  and  Padua  and  on  his  return  to  England,  as  Lumleian 


MEDICAL   BESEABCH   AND   EDUCATION 

lecturer,  gave  most  of  his  time  to  teaching  and  dissection.  It  was 
during  the  second  year  (1616)  of  such  labors  that  he  first  propounded 
his  theory  of  the  circulation  of  the  blood,  but  it  was  not  until  1628  that 
his  complete  work  on  the  subject  was  published.  With  the  discussion 
as  to  the  part  played  by  his  forerunners,  by  Servetus,  Csesalpinum  and 
others  in  elucidating  the  mysteries  of  the  circulation  we  are  not  now 
concerned.  The  honor  of  the  establishment  of  the  theory  is  Harvey's. 
More  than  this,  it  was  the  character  of  his  exhaustive  observations  on 
a  score  of  different  animals  (and  on  the  heart  of  the  chicken  in  ovo), 
his  logical  reasoning,  and  his  convincing  experiments  that  finally  led 
to  the  correct  solution  and  to  the  resurrection  of  a  new  method  in 
medicine,  that  of  experimental  physiology.  It  may  be  remembered 
that  Galen  has  been  referred  to  as  the  first  experimental  physiologist; 
after  fourteen  hundred  years  he  was  followed  by  Harvey;  then  came 
Haller  and  Hunter,  prophets  of  that  modern  experimental  physiology 
which  was  in  the  nineteenth  century  to  advance  along  all  lines  and  to 
give  to  medicine  a  scientific  foundation. 

It  is  difficult  to  overestimate  the  significance  of  Harvey's  discovery 
of  the  circulation  of  the  blood.  Sir  Thomas  Brown  considered  it 
greater  than  Columbus's  discovery  of  America;  Hunter  ranked  it  with 
that  of  Columbus  and  that  of  Copernicus.  Certainly  it  opened  a  new 
world  in  medicine.  Progress,  however,  did  not  immediately  follow 
Harvey's  discovery,  though  four  years  after  his  death  the  capillary 
system,  a  link  necessary  to  the  completion  of  his  doctrine  of  the  circula- 
tion, was  discovered  by  Malpighi.  The  period,  was,  however,  one  of 
detailed  observation  in  anatomy,  and  despite  the  work  of  Malpighi  and 
Borelli,  experimental  physiology  languished  until  the  time  of  Haller 
(1708-1777),  who  made  additions  to  the  knowledge  of  the  mechanics 
of  respiration,  established  the  theory  of  irritability  as  a  specific  property 
of  muscle  and  made  important  observations  in  embryology.  How 
prophetic  of  the  advances  of  the  nineteenth  century  are  the  problems 
with  which  Haller  and  Hunter  busied  themselves.  The  study  of  the 
irritability  of  muscle  suggests  physiological  instruments  of  precision, 
and  embryology  implies  the  compound  microscope  and  the  microtome, 
the  familiar  instruments  of  the  latter  nineteenth-century  investigator 
in  medicine.  Hunter's  problems — phlebitis,  aneurism,  syphilis,  inflam- 
mation, the  repair  of  wounds,  the  coagulation  of  the  blood — remind 
one  of  many  phases  of  present-day  investigation.     Prophetic  also  of  the 


BE  SEARCH    IN   MEDICINE  15 

phenomenal  development  of  pathology,  under  Eokitansky  and  Virchow, 
was  Morgagni's  publication  in  1761  of  his  "  Seats  and  Causes  of  Dis- 
ease/' the  first  systematic  effort  to  correlate  clinical  manifestations  with 
pathological  anatomy.  Likewise,  the  introduction  by  Jenner  (1796) 
of  the  systematic  practise  of  vaccination  against  small-pox,  presaged 
those  methods  of  prophylaxis  which  within  the  next  century  were  to 
revolutionize  the  methods  of  controlling  many  of  the  infectious  dis- 
eases. We  will  return  in  later  lectures  to  both  Morgagni  and  Jenner 
and  their  influence  on  the  development  of  pathology  and  immunology, 
but  here  they  serve  with  Hunter  and  Haller  to  illustrate  how  a  few 
individuals  with  a  genius  for  accurate  observation,  sound  thinking  and 
exact  experimentation  may  by  their  contributions  foreshadow  the  activi- 
ties of  a  succeeding  century,  and  be  the  forerunners  of  new  schools  of 
thought.  Their  labors  with  those  of  Vesalius,  Pare  and  Harvey  are 
examples  of  that  effort  which,  isolated  though  it  was,  during  the  three 
or  four  centuries  preceding  the  year  1800  and  proceeding  as  it  did  from 
individaals  living  and  working  in  widely  separated  places,  nevertheless, 
constituted  in  the  sum  a  sound  body  of  knowledge  readily  available  to 
future  investigators,  equipped  with  new  methods.  With  the  exception 
of  Pare  no  one  of  these  men  was  thoroughly  appreciated  by  his  contem- 
poraries. Vesalius  was  reviled  and  forced  to  leave  Padua,  Hunter's 
ligation  of  a  vessel  in  continuity  was  at  first  ridiculed  and  Harvey's 
discovery,  like  others  in  various  fields,  because  not  possible  at  once  of 
practical  application,  did  not  appeal  to  medical  men  who  still  clung 
to  the  traditional  teachings  of  Galen.  It  was  the  period  of  genius 
working  alone  without  the  approval  of  the  profession,  without  the  sup- 
port of  universities  and  laboratories,  and  without  the  means  of  publica- 
tions and  the  means  of  travel  that  to-day  render  almost  immediately 
available  new  advances,  achievements  and  theories.  One  had  to  journey 
to  the  city  or  country  of  this  or  that  authority  or  investigator  to  get  his 
views.  Merz,  in  his  "  History  of  European  Thought  in  the  Nineteenth 
Century,"  gives,  as  examples  of  such  voyages  of  discovery  Voltaire's 
visit  "to  England  in  1728,  where  he  found  the  philosophy  of  Newton 
and  Locke,  at  that  time  not  known  and  therefore  not  properly  appre- 
ciated in  France;  the  journey  of  Adam  Smith  in  1765  to  France,  where 
he  became  acquainted  with  the  economic  system  of  Quesnay  " ;  and  the 
visit  of  "Wordsworth  and  Coleridge  to  German}^,  whence  the  latter 
brought  to  England  the  new  philosophy  of  Kant  and  Schelling."     It  is 


16  MEDICAL   BESEABCH    AND    EDUCATION 

not  surprising  that  under  such  circumstances  advances  in  medicine,  as 
in  science  generally,  were  few  and  far  between. 

How  the  change  from  individual  to  organized  effort  came  about, 
and  how  medicine  became  the  subject  of  investigation  by  scientific 
methods  in  laboratories  established  for  that  purpose  will  be  shown  in 
the  next  lecture. 


LECTUEE    II 

The  Development  of  Laboratories  for  the  Medical   Sciences 

It  would  be  interesting  to  trace  in  the  events  and  activities  of  the 
later  years  of  the  eighteenth  and  early  years  of  the  nineteenth  cen- 
turies that  development  of  general  thought  which  exerted  indirectly 
an  influence  on  modern  medicine;  but,  under  the  circumstances,  I  can 
outline  only  a  few ;  it  was  the  period  of  the  struggle  for  American  Inde- 
pendence, of  the  French  Eevolution  and  of  England's  abolition  of  the 
slave  trade.  The  world  was  becoming  wiser  and  more  humane;  men  and 
women  were  no  longer  hanged  for  witchcraft;  the  principle  of  educa- 
tion for  all  was  being  recognized ;  and  it  was  also  at  this  time  that  the 
insane  were  treated  as  persons  ill  of  disease  and  not  as  prisoners,  to  be 
chained  together  and  crowded  into  filthy  pens  until  death  should  end 
their  misery. 

Captain  Cook  was  enlarging  the  boundaries  of  the  known  world, 
Daguerre  was  establishing  the  art  of  photography,  Murdoch  was  de- 
veloping the  use  of  coal  gas  as  an  illuminant,  Watts  was  improving  the 
steam  engine,  Fulton  was  concerned  with  the  steamboat  and  Stephen- 
son somewhat  later  with  the  steam  locomotive.  Machinery  was  being 
invented  to  replace  hand  labor,  and  advances  in  technical  and  indus- 
trial procedures  were  rapidly  following  one  another. 

It  was  likewise  a  period  marked  by  the  rise  of  great  chemists  and 
physicists,  as  Lavoisier,  Scheele,  Priestley,  Avogadro,  Dalton,  Gay-Lus- 
sac,  Davy,  Volta,  Franklin  and  Galvani;  great  naturalists  as  Cuvier, 
Humboldt  and  Lamarck;  and  great  astronomers  and  mathematicians 
as  Herschel  and  Laplace.  At  the  time,  the  activities  of  these  men  were 
not  seen  to  be  directly  contributory  to  the  science  and  practise  of  medi- 
cine, but  as  the  years  went  on  and  it  became  more  and  more  evident — 
largely  as  the  result  of  their  work — that  knowledge  was  to  be  gained 


BE  SEARCH   IN   MEDICINE  17 

not  by  establishing  all-embracing  systems  of  philosophy,  but  by  the  ac- 
cumulation of  facts  through  exact  observation  and  experiment,  their 
methods  became  the  property  of  all  branches  of  science  and  so,  natu- 
rally, of  medicine.  In  addition  to  method,  moreover,  these  men  offered, 
in  the  fruits  of  their  labors,  a  not  inconsiderable  amount  of  data  of 
direct  value  to  medicine,  in  the  establishing  of  sound  principles  of 
physiology. 

In  the  meantime,  however,  the  practise  o:^  medicine  labored  under 
great  difficulties  and  was  largely  a  matter  of  empiricism.  "Without  a 
knowledge  of  etiology,  without  pathological  anatomy,  that  firm  founda- 
tion for  diagnosis,  and  without  a  rational  therapy  it  could  be  nothing 
else.  Mercury,  cinchona,  cathartics  and  bleeding  were  the  general 
methods  of  treatment.  Great  and  noble  men  filled  the  universities  and 
hospitals ;  they  labored  conscientiously,  and  elaborated  systems,  and  did 
what  they  could  to  relieve  human  misery,  but  to  the  advance  of  the 
science  of  medicine  they  contributed  little  or  nothing. 

Anatomy  as  a  descriptive  science  dealing  with  adult  structures  and 
their  gross  appearance  had  been  well  established;  but  it  waited  for  its 
fullest  development  upon  the  methods  destined  to  establish  histology 
and  embryology.  Experimental  physiology,  except  as  Haller  and 
Hunter  had  influenced  it,  was  an  unknown  field,  soon,  however,  to  be 
widely  explored  as  the  result  of  the  introduction  of  instruments  of  pre- 
cision and  analytical  methods.  Pathology,  dependent  upon  the  methods 
of  histology  and  physiology  was  marking  time,  and,  in  turn,  internal 
medicine  awaited  the  development  of  pathological  anatomy.  Surgery, 
slowly  improving  technical  procedures,  likewise  marked  time  until 
anesthesia  and  asepsis  opened  new  worlds  to  it. 

The  advance  in  these  general  subjects  it  is  my  intention  to  follow 
along  the  lines  of  physics,  chemistry  and  biology,  as  they  developed  in 
France,  England  and  Germany.  And,  if  in  the  course  of  this  presenta- 
tion I  have  much  to  say  about  the  work  shops  of  these  sciences,  it  is 
because  universities,  laboratories  and  hospitals,  as  well  as  societies  and 
journals,  represent  the  visible  machinery  of  nineteenth  century  re- 
search in  medicine,  and  whether  we  regard  them  as  the  cause  or  the 
effect  of  the  awakening  of  70  years  ago,  they  to-day  constitute  our  hope 
for  the  future  of  medical  research. 

It  is  difficult  to  select  a  starting  point  for  a  systematic  survey. 
Chemistry,  however,  appears  to  promise  the  most  direct  course,  for  it 

3 


18  MEDICAL   BESEABCH   AND    EDUCATION 

was  toward  the  end  of  the  eighteenth  century  that  Lavoisier  intro- 
duced the  modern  scientific  spirit  of  exact  measurement  as  applied  to 
chemical  phenomena  and  through  it  established  the  great  reform  re- 
sponsible for  modern  chemical  knowledge  and  research.  Carbonic  acid 
had  already  been  discovered  by  Black,  hydrogen  by  Cavendish,  nitrogen 
by  Eutherford  and  ammonia  by  Priestley;  oxygen  had  been  studied  by 
Priestley,  Scheele  and  Lavoisier,  so  that  with  Dalton's  atomic  theory, 
Cavendish's  analysis  of  the  air  and  Lavoisier's  study  of  oxidation,  defi- 
nite knowledge  of  the  chemistry  of  air  and  water,  and  of  combustion 
and  respiration  was  at  hand  for  the  use  of  the  physiologist  and  physio- 
logical chemist.  At  about  the  same  time  the  science  of  crystallography 
was  established  and  somewhat  later  Davy's  use  of  the  electric  current 
in  the  study  of  the  alkaline  earths. 

In  a  word,  activity  in  chemistry  was  evident  everywhere,  and  theory 
and  methods  were  being  rapidly  developed,  but  nowhere  was  chemistry 
a  part  of  university  study.  Berzelius,  Gay-Lussac  and  others  had  or- 
ganized laboratories  for  the  training  of  chemists,  but  it  remained  for 
the  University  of  Giessen  to  establish  the  first  chemical  laboratory 
under  the  control  of  a  university.  Here,  Liebig  in  1826,  when  only  21 
years  of  age,  opened  his  laboratory  and  began  his  labors  in  organic 
chemistry. 

The  event  is  of  importance,  not  only  for  chemistry,  but  for  medical 
research  in  general,  for  the  admission  of  chemistry  to  the  university 
was  the  first  step  towards  the  overthrow  of  the  "  natur-philosopher " 
and  hence  to  the  development  of  that  modern  science  which  has  made 
German  universities  so  justly  famous.  It  is  also  important  from 
another  point  of  view;  in  France  science  had  been  the  work  of  the 
academicians,  in  England  of  workers  in  private  laboratories  or  in  those 
supported  by  commercial  companies;  by  the  new  departure  at  Giessen, 
the  precedent  for  university  laboratories  was  established,  and  the  world 
has  since  followed  Germany's  lead. 

This  laboratory  of  Liebig  at  Giessen  was  a  success  immediately  and 
became  the  training  school  for  most  of  the  eminent  chemists  outside  of 
Paris.  The  training  offered  at  Giessen  was  systematic  and  methodical 
in  qualitative,  quantitative  and  organic  analysis.  In  his  autobiography, 
Liebig  speaks  of  the  difficulty  "  as  the  numbers  increased,  of  the  prac- 
tical teaching  itself  "  but  "  a  progressive  way  of  working  "  was  thought 
out  and  tried,  I  can  not  refrain  from  quoting  his  own  words  concern- 
ing the  development  of  the  work  in  organic  chemistry. 


BE  SEARCH    IN    MEDICINE  19 

The  first  years  of  my  residence  at  Giessen  were  almost  exclusively  devoted 
to  the  improvement  of  organic  analysis,  and  with  the  first  successes  there  began 
at  the  small  university  an  activity  such  as  the  world  had  not  yet  seen.  .  .  .  Every 
one  was  obliged  to  find  his  own  way  for  himself.  .  .  .  We  worked  from  dawn  to 
the  fall  of  night,  there  were  no  recreations  and  pleasures  at  Giessen.  The  only 
complaints  were  those  of  the  attendant,  who  in  the  evenings,  when  he  had  to 
clean,  could  not  get  the  workers  to  leave  the  laboratory. 

In  another  place  he  says : 

I  have  found  among  all  who  frequent  this  laboratory  (Giessen)  for  technical 
purposes  a  prominent  inclination  to  occupy  themselves  with  applied  chemistry. 
They  usually  follow  hesitatingly  and  with  some  suspicion  my  advice  to  leave 
alone  all  this  time-absorbing  drudgery,  and  simply  to  become  acquainted  with 
the  necessary  ways  and  means  of  solving  purely  scientific  questions. 

Such  were  the  habits,  the  methods  of  work  and  the  ideals  of  the  man 
who  in  four  years  established  that  simple  and  accurate  method  of  or- 
ganic analysis  known  by  his  name.  From  his  labors  and  those  of 
Wohler,  who  in  1828  announced  the  first  synthesis  of  an  organic  sub- 
stance (urea)  dates  our  modern  organic  chemistry.  Liebig  represent- 
ing the  school  of  Gay-Lussac  and  Wohler  that  of  Berzelius,  one  at 
Giessen  and  the  other  at  Gottingen,  serve  as  an  interesting  example 
of  scientific  cooperation  to  develop  a  new  science. 

Liebig's  work  led  directly  to  those  activities  which  we  now  group 
under  the  term  physiological  or  biological  chemistry,  but  physiology 
was  at  this  time  making  rapid  strides  along  another  line  of  attack — the 
application  of  the  principles  of  mechanics  and  physics.  The  part  of 
physics  in  medicine  from  Galileo  to  Eoentgen  is  one  of  the  most  fasci- 
nating phases  of  the  history  of  medicine ;  in  principle  and  practise,  in 
theory  and  science,  its  influence  has  been  one  of  fundamental  importance 
and  in  its  application  to  methods  of  clinical  diagnosis  it  shares  equally 
with  pathological  anatomy  in  the  awakening  of  modern  clinical  medi- 
cine. The  first  widely  reaching  application  was  in  Harvey's  interpre- 
tation of  the  circulation  of  the  blood  and  the  action  of  the  heart,  but  it 
was  not  until  organized  physiological  laboratories  had  been  instituted 
that  the  application  of  the  principle  of  physics  bore  abundant  fruit. 
To  recall  the  state  of  physics  at  that  time  it  is  only  necessary  to  state 
that  the  work  of  Galvani  and  Volta  was  completed  and  that  Ampere 
and  Ohm,  Faraday  and  Wheatstone,  were  still  active.  Charles  Bell  had 
already  (1811)  given  to  England  the  second  of  two  great  discoveries  in 
physiology,  the  differentiation  of  sensory  and  motor  nerves.  Haller,  as 
we  have  seen,  had  in  the  preceding  century  presented  and  discussed  the 


20  MEDICAL   EESEABCH   AND   EDUCATION 

irritability  of  muscle.  The  time  was  at  hand  for  the  study  of  the  gen- 
eral physics  of  muscle  and  nerve  and  the  special  senses.  Ernst  Weber 
announced  the  principles  of  his  psycho-physics  in  1825  and  Johannes 
Miiller  those  of  his  physical  chemistry  in  1826 ;  Purkinje  had  already 
established  the  first  university  laboratory  of  physiology  in  1824  at  Bres- 
lau;  in  1838  the  celebrated  physiological  institute  at  Berlin  was  formed 
under  the  direction  of  Miiller  and  in  1840  Ernst  Weber  was  made  pro- 
fessor of  physiology  at  Leipzig,  From  these  two  centers,  Berlin  and 
Leipzig,  from  Johannes  Miiller  and  Ernst  H.  Weber,  came  a  great  vol- 
ume of  minute  investigations  based  on  exact  methods  of  inquiry.  Both 
schools  were  largely  busied  with  studies  of  the  mechanism  of  the  per- 
ceptions of  the  senses,  that  of  Weber  tending  to  include  mental  phe- 
nomena, thus  anticipating  the  modern  school  of  psychologists,  that  of 
Miiller  including  not  only  the  methods  of  physics,  but  also  those  of 
general  biology.  Miiller  (1801-1858)  was  indeed  the  last  of  a  school 
which  attempted  to  embrace  all  of  the  territory  of  biology  in  its  broad 
sense;  a  territory  which  now  has  its  separate  and  distinct  fields  of 
morphology,  physiology  and  chemistry.  He  may,  however,  be  regarded 
as  responsible  for  some  of  the  divisions  into  which  the  older  biology  has 
been  split,  and  for  the  impulse  to  new  lines  of  study,  for  he  was  the 
teacher  of  the  masters  who  came  in  time  to  occupy  high  places  in  biol- 
ogy, of  Schwann  and  Henle  in  anatomy,  of  Du  Bois-Eeymond  and 
Helmholtz  in  physiology  and  of  Virchow  in  pathological  anatomy.  It 
is  not  surprising  therefore  that  it  was  the  proud  boast  of  this  school 
that  not  only  had  it  dispelled  the  vague  notions  of  the  old  metaphysical 
school  and  established  in  its  stead  the  true  scientific  spirit,  but  that 
it  had  filled  so  many  of  the  chairs  of  medicine,  physiology  and  anatomy 
in  the  German  universities  that  the  scientific  spirit  has  been  applied  to 
"  every  branch  of  medical  science,  which  it  has  in  consequence  drawn 
into  the  circle  of  the  exact  or  mechanical  sciences."     (Merz.) 

This  is  not  the  place  to  go  into  detail  concerning  the  investigations 
of  Miiller  and  his  school  of  physiology.  His  law  of  "  specific  energies," 
Du  Bois-Eeymond's  electro-physiology  and  Helmholtz's  work  on  musical 
acoustics  and  physiological  optics  indicate  the  character  and  scope  of 
the  work.  The  keynote  of  it  all  Miiller  himself  has  expressed  in  his 
"  Elements  of  Physiology  "  as  follows : 

Though  there  appears  to  be  something  in  the  phenomena  of  living  beings 
which  can  not  be  explained  by  ordinary  mechanical,  physical  or  chemical  laws, 


BESEAECH   IN    MEDICINE  21 

much  may  be  explained,  and  we  may  without  fear  push  these  explanations  as 
far  as  we  can,  so  long  as  we  keep  to  the  solid  ground  of  observation  and 
experiment. 

These  principles  and  the  labors  of  this  school  were  advanced  wonder- 
fully, in  1847,  by  Ludwig's  invention  of  the  kymograph  and  the  elabo- 
ration of  methods  of  graphic  registration,  factors  which  established 
this  phase  of  physiology  on  a  sound  basis  and  exerted  an  influence  which 
medicine  feels  to  this  day.  This,  however,  was  not  the  only  influence 
of  Miiller.  As  a  biologist  with  general  interests  he  stimulated  general 
biological  research  and  it  was  undoubtedly  this  influence  exerted 
through  Schwann  that  led  the  latter  to  grasp  the  importance  of 
Schleiden's  work  on  vegetable  cells  and  to  apply  the  observations  of  the 
latter  to  the  cells  of  the  animal  body. 

But  although  the  cell  doctrine,  in  its  modern  conception,  is  the  re- 
sult of  the  work  of  these  two  men,  Schleiden  and  Schwann,  it  is  not  to 
be  supposed  that  they  were  the  first  to  study  cells,  for  before  Schleiden 
considerable  attention  had  been  given  to  the  structure  of  vegetable 
tissues.  Eobert  Hooke  in  1665  had  given  to  the  spaces  in  cork  and 
similar  structure  the  names  of  "cells";  Malpighi  (1674)  and  Grew 
(1683)  had,  as  far  as  their  low  power  lenses  would  allow,  described  plant 
tissue  as  made  up  in  part  of  cell-like  cavities  provided  with  firm  walls 
and  filled  with  fluid,  and  in  part  of  long  tube-like  vessels.  Treviranus, 
in  1806,  demonstrated  that  these  tubes  arose  as  the  result  of  cells  be- 
coming attached  end  to  end,  the  intervening  ends  eventually  disappear- 
ing. The  nucleus  of  the  cell  had  been  discovered  in  1831  by  Brown, 
who,  however,  failed  to  realize  its  importance.  Not  so  Schleiden.  He 
attached  great  importance  to  the  nucleus  and  by  the  numerous  observa- 
tions (1839-1843)  which  he  brought  forward  was  able  to  formulate  a 
definite  cell  theory  for  plants;  later  when  this  theory  was  applied  to 
animal  tissues  and  developed  by  Schwann  and  Virchow  it  became  an 
influence  as  great  as  that  of  the  theory  of  evolution,  in  the  development 
of  modern  biology. 

Schwann,  who  was  at  the  time  an  assistant  of  Miiller,  received  di- 
rectly from  Schleiden  the  impulse  to  compare  animal  and  vegetable 
cells.  While  carrying  out  for  Miiller  the  experimental  study  of  nerve 
and  muscle,  necessary  for  the  proper  preparation  of  his  chief's  great 
book  on  physiology,  he  became  interested  in  the  histological  study  of 
these  structures  and  it  was  at  this  time  that  he  described  the  nerve 


22  MEDICAL   BESEABCH   AND   EDUCATION 

fiber  sheath  which  now  bears  his  name.  Once,  when  he  was  dining  with 
Schleiden  in  1837,  the  conversation  turned  to  the  nuclei  of  vegetable 
cells,  Schleiden's  description  of  these  recalled  to  Schwann  similar 
structures  which  he  had  seen  in  animal  tissues.  The  resemblance  be- 
tween the  animal  and  plant  cells  was,  without  loss  of  time,  confirmed  by 
both  observers  and  the  result  was  Schwann's  famous  paper  (1839)  on 
the  accordance  in  structure  of  animal  and  plant  tissues. 

It  is  difficult  for  the  student  of  to-day,  thoroughly  drilled  concern- 
ing the  details  of  cell  structure  in  his  courses  in  normal  and  pathological 
histology,  to  realize  that  only  a  little  over  70  years  ago  the  essential 
feature  of  the  animal  cell,  the  nucleus,  was  not  recognized,  and  that  it 
was  a  botanist  who  first  brought  the  subject  to  the  attention  of  a  physi- 
ologist. Medicine  in  all  its  phases  has  advanced  rapidly  along  the  path 
thus  opened  up  by  Schleiden  and  Schwann.  To-day  we  are  interested 
above  all  other  things  in  the  chemistry  of  the  cell,  but  from  the  time  of 
Schwann  to  the  time  of  Pasteur  the  study  of  the  morphology  of  the  cell 
in  health  and  in  disease  was  one  of  the  chief  interests  of  scientific 
medicine. 

It  is  not  to  be  supposed,  however,  that  Schwann  had  the  conception 
of  the  cell  which  we  have  to-day.  He,  as  Schleiden  before  him,  made 
faulty  observations  and  drew  faulty  conclusions.  The  important  fea- 
tures of  Schwann's  work  were  the  recognition  of  the  nucleus,  not  the 
cell  wall,  as  the  important  part  of  the  cell,  the  demonstration  of  the 
union  or  grouping  of  the  cells  to  form  tissues,^  and  the  demonstration 
that  the  distinctive  cells  of  the  tissues  of  the  adult  develop  from  the 
undifferentiated  cells  of  the  early  embryo.  The  misconceptions  of  the 
early  histologists  were  natural  when  we  recall  the  great  technical  diffi- 
culties with  which  they  had  to  contend.  The  microtome,  the  micro- 
scope, and  differential  staining  methods,  in  their  present-day  perfection 
did  not  exist  for  them.  It  was  the  day  of  the  razor  and  hand  sectioning. 
The  first  microtome  appears  to  have  been  that  used  by  Professor  His  in 
1866;  the  improvements  leading  to  the  perfection  of  the  present-day 
microtome  did  not  begin  until  1875.     The  development  of  the  objective 

"This  statement  does  not  disregard  the  work  of  Bichat  (1771-1802),  fre- 
quently called  the  "father  of  histology,"  to  whom  is  due  the  credit  of  first 
recognizing  the  fact  that  the  body  was  made  up  of  distinct  and  differing  tissues. 
Bichat 's  results,  however,  were  obtained  by  the  us©  of  chemical  reagents.  He 
used  the  microscope  but  little,  and  his  work,  important  as  it  was,  and  antedating 
the  cell  theory  by  40  years,  can  not  be  considered  as  leading  to  the  development 
of  the  cell  theory. 


BESEABCE   IN   MEDICINE  23 

of  the  compound  microscope  was  just  beginning  in  Schwann's  time 
(1830).  Although  iodine  was  early  used,  it  was  not  until  about  1857 
that  Gerlach  called  attention  to  carmine,  the  first  nuclear  stain  to  be 
introduced  into  histological  technic.  At  first,  tissues  were  examined 
only  in  the  fresh  state  and  even  later  when  hardened  they  were  not 
imbedded  as  now  in  celloidin  or  paraffin,  but  placed  between  vegetable 
pith  or  blocks  of  amyloid  organs  during  the  process  of  cutting. 

Surely  the  technical  difficulties  were  great  and  we  are  not  surprised 
that  both  Schleiden  and  Schwann  believed  new  cells  to  be  formed 
through  a  process  of  "crystallization"  from  a  "mother  liquor"  or 
cytoblastema  and  that  the  cell  was  a  vesicle  with  a  solid  wall.  This 
question  of  minute  structure  and  that  of  mitosis  yielded  eventually  to 
improvements  in  technic  and  Schleiden's  theory  of  the  formation  of 
cells  de  novo  was  discarded,  and  we  know  from  Virchow's  famous 
aphorism  "  omnis  cellula  e  cellula  "  that  in  his  time  it  was  established 
that  cells  arose  only  by  the  division  of  preexisting  cells.  This  general 
law  was  the  result  largely  of  the  work  of  botanists,  as  Hugo  von  Mohl 
and  Nageli,  and  was  applied  by  Virchow  (1858)  to  animal  tissues  only 
after  much  work  had  been  done  on  such  tissues  by  Kolliker,  Eeichert 
and  Eemak.  It  was  not  until  1873  (Anton  Schneider)  that  an  insight 
into  the  details  of  cell  division  was  gained  and  it  was  1882  when  the 
part  of  the  nucleus  in  karyokinesis  was  satisfactorily  demonstrated  and 
Flemming  could  supplement  Virchow's  aphorism  with  another  "  omnis 
nucleus  e  nucleo." 

Thus  did  Schleiden,  a  botanist  of  the  University  of  Jena,  and 
Schwann,  assistant  (1824-1838)  to  Miiller,  establish  one  of  the  most 
brilliant  and  most  important  generalizations  of  the  century,  which 
became  at  once  the  basis  of  all  morphological  studies,  and,  as  applied 
by  Virchow,  placed  pathology  on  a  scientific  basis,  and  has  continued 
as  a  result  of  its  general  biological  applications — to  development,  in- 
heritance and  immunity — to  influence  medicine  profoundly.  As  Ver- 
worn  has  said : 

It  is  to  the  cell  that  the  study  of  every  bodily  function  sooner  or  later 
drives  us.  In  the  muscle  lies  the  problem  of  the  heart  beat  and  that  of  muscular 
contraction;  in  the  gland  cell  resides  the  cause  of  secretion;  in  the  epithelial 
cell,  in  the  white  blood  corpuscle,  lies  the  problem  of  the  absorption  of  the  food, 
and  the  secrets  of  the  mind  are  hidden  in  the  ganglion  cell. 

It  will  be  necessary  to  return  to  the  cell  theory  again  in  discussing 
the  development  of  pathology,  but  we  may  leave  it  for  the  moment  to 


24  MEDICAL   EESEABCH   AND   EDUCATION 

trace  one  other  line  of  advance  made  by  the  physiologist;  an  advance 
in  that  phase  of  the  subject  which  Du  Bois-Eeymond  characterized,  in 
1880,  as  "  vivisection  and  zoochemistry "  in  contrast  to  the  electro- 
physiology  of  nerve  and  muscle  with  which  his  own  name  is  so  closely 
linked,  and  in  contrast  also  to  the  phase  of  physiology  in  which  his- 
tology, following  the  lead  of  Schwann,  was  playing  so  large  a  part. 
This  third  field  in  physiology  necessitates  a  shift  of  scene  to  France  and 
Claude  Bernard  and  his  school  and  the  study  of  the  functions  of  organs 
and  their  secretions. 

Claude  Bernard  (1813-1878)  was  the  pupil  and  successor  of 
Magendie.  Magendie  did  many  things,  but  best  of  all  he  made  "  the 
experimental  method  the  corner  stone  of  normal  and  pathological  physi- 
ology and  pharmacology."  (Welch.)  By  this  method  he  demon- 
strated, as  Charles  Bell  had  divined,  the  essentially  different  functions 
of  the  anterior  and  posterior  roots  of  spinal  nerves.  Also  he  founded 
a  journal  of  experimental  physiology. 

Bernard,  departing  widely  from  Magendie's  work,  followed  in  his 
researches  one  main  idea,  the  action  of  the  nervous  system  on  the 
chemical  changes  which  constitute  the  basis  of  nutrition  and  this 
problem  he  attempted  to  solve  by  either  direct  experimental  investiga- 
tion of  nerves,  or  by  chemical  researches  or  by  a  combination  of  both 
methods.  His  most  important  discoveries  were  the  demonstration 
(1)  of  the  significance  of  the  pancreatic  juice  in  digestion;  (2)  the 
glycogenic  function  of  the  liver  and  (3)  the  vasomotor  system.  These 
investigations  (1850-1860)  with  those  of  Ludwig  (1851)  on  the 
mechanism  of  the  secretion  of  the  glands,  with  the  earlier  observation 
on  gastric  digestion  made  by  our  own  countryman,  "William  Beaumont 
(1833),  and  the  discovery  of  pepsin  by  Schwann  (1835)  represent  the 
principles  out  of  which  our  present  conception  of  the  physiology  of 
digestion  has  developed.  Not  only  did  Bernard  make  discoveries  and 
work  out  the  lines  of  progress  for  the  study  of  the  outward  or  external 
secretions  of  glands,  but  as  a  result  of  his  study  of  the  influence  of  the 
liver  on  carbohydrate  metabolism,  he  formulated  the  theory  of  "  in- 
ternal secretions,"  which  represents  a  field  of  physiology  cultivated  in 
the  past  few  years  with  the  greatest  success  and  still  full  of  promise  for 
the  future. 

Bernard  has  the  distinction  of  being  the  first  man  of  science  to 
whom  France  accorded  a  public  funeral,  a  recognition  not  alone  of 


BE  SEARCH    IN   MEDICINE  25 

personal  worth,  but  also  of  the  nation's  debt  to  science  and  to  research 
in  the  field  of  medicine. 

Thus  far  I  have  presented  the  beginnings  of  those  branches  of  medi- 
cine which  deal  with  normal  structure  and  function.  Next  in  order  of 
development  comes  that  science  which  is  concerned  with  the  study  of 
disease,  pathology  and  upon  which  are  based  sound  diagnosis  and 
rational  therapy  and  for  this  reason  the  science  of  most  interest  in 
medicine.  Pathology  owes  its  position  as  a  recognized  science  to  the 
genius  of  Virchow,  but,  in  its  development,  it  also  owes  much  to  the 
period  I  have  just  discussed,  as  I  will  show  in  due  time.  To  present 
this  development  properly  it  is  necessary  to  turn  back  to  1761  and 
Morgagni.  I  must  again  remind  you  that  in  Morgagni's  time  medical 
science  can  hardly  be  said  to  have  existed.  It  was  the  period  of  a  vague 
philosophy  which  attempted  to  systematize  diseases  according  to  symp- 
toms, with  no  reference  to  the  anatomical  conditions  causing  the  symp- 
toms. It  was  Morgagni  who  first  insisted  that  the  clinical  history 
should  be  set  side  by  side  with  the  results  of  the  autopsy  and  who  by 
his  publication  "  De  Sedibus  et  Causis  Morborum "  threw  the  first 
gleam  of  light  on  the  causes  and  nature  of  diseased  processes,  and  thus 
gave  a  stimulus  to  the  study  of  pathological  anatomy.  Before  Mor- 
gagni's time,  and  for  some  time  after,  pathological  anatomy  was  mainly 
concerned  with  the  recording  of  the  rare  and  curious,  with  malforma- 
tions and  obvious  departures  from  the  normal  type;  observations  often- 
times interesting,  but  not  systematized  or  harmonized.  Morgagni  is 
responsible  for  the  maxim  that  observations  should  be  "  weighed  not 
counted,"  and  it  was  undoubtedly  this  point  of  view  which  influenced 
his  observations  and  led  eventually  to  the  doctrine  that  most  diseases 
were  to  be  explained  by  changes  in  the  organs  of  the  body. 

Another  step  in  advance  was  taken  when  Bichat,  about  a  quarter  of 
a  century  later,  referred  disease  to  the  tissues  of  the  organs.  In  the 
meantime  John  Hunter  (1728-1793)  had  applied  to  the  problems  of 
clinical  medicine  methods  which  we  now  recognize  as  those  of  experi- 
mental pathology.  Still  pathology  was  not  a  science;  it  was  not  sys- 
tematized and  it  had  no  underlying  principle.  The  systematization  of 
pathological  anatomy  came  through  Eokitansky^  (1804-1878)  and  the 
underlying  principle  of  pathology  from  Virchow  in  1858. 

*  A  worthy  predecessor  of  Kokitansky  was  Johann  Fr.  Meckel,  whose 
"Handbuch  d.  patholog.  Anatomie"  was  published  at  Halle  in  1804,  the  year 
of  Eokitansky 's  birth. 


26  MEDICAL   BESEAECE   AND   EDUCATION 

Eokitansky,  the  father  of  pathological  anatomy,  was  an  assistant  to 
Johann  Wagner,  later  succeeding  him  in  1834  as  prosector  and  finally 
in  1844  as  professor  of  pathological  anatomy  at  Vienna.  Wagner  had 
encouraged  the  application  to  pathology  of  the  methods  of  anatomy, 
and  the  publication  of  Eokitansky's  "  Handbuch  der  pathologischen 
Anatomic,"  completed  in  1846  (one  year  before  Virchow's  "  Archiv  " 
was  founded),  presented  to  the  profession  the  results  of  a  most  thor- 
ough study  of  the  details  of  pathological  anatomy.  It  is  said  that 
Eokitansky  performed,  as  the  basis  for  his  classifications,  more  than 
thirty  thousand  autopsies.  His  position  in  pathology  has  been  likened 
to  that  of  Linnaeus  in  botany.  "  Even  to-day  nothing  can  equal  the 
accuracy  of  Eokitansky's  observations.  There  are  few  things  he  did 
not  see.  Wlien  some  lesion  or  combination  of  lesions  seems  entirely 
new,  it  is  often  only  necessary  to  go  back  to  the  work  of  Eokitansky  to 
find  that  he  had  observed  and  accurately  described  it."  (Councilman.) 
Although  he  encouraged  the  development  of  pathological  histology, 
pathological  chemistry  and  experimental  pathology,  he  took  no  active 
part  in  these  subdivisions  of  pathology  and  used  the  microscope  but 
little.  He  seems  to  have  been  content  with  the  establishment  of  patho- 
logical anatomy  as  a  descriptive  science. 

Between  Eokitansky's  work  and  Virchow's  cell  theory  there  is  no 
obvious  connection.  Between  Morgagni,  Bichat  and  Virchow  we  have 
an  interesting  link,  that  formed  by  the  successive  theories  which  placed 
disease  in  the  organs,  the  tissues  and  the  cell,  respectively.  Eokitansky 
worked  with  the  organs  and  tissue  and  had  no  influence  in  carrying  the 
quest  on  to  the  cell.  The  influences  which  led  Virchow  to  the  latter  are 
wholly  those  we  have  discussed  in  the  story  of  physiology  and  its  begin- 
nings, the  personal  influence  of  Johannes  Miiller,  Schwann's  writings 
and  the  results  of  the  application  to  medicine  of  the  methods  of  physics 
and  chemistry.  That  he  appreciated  the  importance  of  the  relations 
of  pathology,  on  the  one  hand,  to  physiology,  and  on  the  other  to  clinical 
medicine  is  shown  in  the  title  of  his  Archives  established  in  1847.  It  is 
not  surprising,  therefore,  that  he  was  not  satisfied  with  the  pathology  as 
merely  the  descriptive  and  classifying  science  of  Eokitansky  and  that  he 
was  the  first  to  recognize  that  pathology  was  the  study  of  life  under 
abnormal  circumstances,  and  that  chemistry,  physiology  and  embry- 
ology had  a  direct  bearing  on  pathology  and  that  the  methods  of  all 
the  other  natural  sciences  should  be  applied  to  the  elucidation  of  the 
problems  of  pathology  and  thus  to  those  of  medicine. 


BESEABCE    IN    MEDICINE  27 

Virchow's  "  cellular  pathology/'  as  announced  in  its  final  form  in 
1858,  must  be  considered  as  a  general  biological  principle  as  important 
in  the  field  of  its  application  as  Darwin's  "  Origin  of  Species "  pub- 
lished one  year  later. 

It  is  said  that  Virchow  first  began  the  observations  which  culmi- 
nated in  his  doctrine  of  cellular  pathology  in  his  student  days,  while 
serving  as  an  assistant  in  the  eye  clinic  of  the  Berlin  Hospital.  Here 
he  became  interested  in  the  fact  that  in  keratitis  and  wounds  of  the 
cornea  healing  took  place  without  the  appearance  of  plastic  exudate. 
This  led  to  an  investigation  which  indicated  the  occurrence  of  repair 
by  the  multiplication  of  preexisting  cells.  These  studies  led  eventually 
to  his  theory,  which  Lord  Lister  has  described  as  the  "  true  and  fertile 
doctrine  that  every  morbid  structure  consists  of  cells  which  have  been 
derived  from  preexisting  cells  as  a  progeny."  In  this  theory  he  brought 
pathological  processes  into  relation  with  normal  growth,  hence  his 
axiom  "  omnis  cellula  e  cellula."  This  was  the  underlying  principle, 
which,  following  Eokitansky's  work  in  classification,  gave  pathology  a 
place  among  the  biological  sciences.  With  his  cell  doctrine  as  a  guide 
he  made  many  important  contributions  to  histology  both  normal  and 
pathological,  and  outlined  a  classification  of  new  growths  which  is  the 
basis  of  all  present-day  knowledge  of  tumors. 

With  his  activities  as  anthropologist-archeologist  we  are  not  espe- 
cially concerned  except  as  they  indicate  the  wide  range  of  his  interests. 
He  was  one  of  the  founders  of  the  German  Anthropological  Society, 
and  later  its  president,  and  made  expeditions  with  Schliemann  to  Troy, 
Egypt,  Nubia  and  the  Peloponnese. 

Of  vast  importance  to  medicine,  however,  was  his  establishment  of 
the  first  pathological  laboratory,  at  the  time  he  returned  (in  1855)  to 
Berlin  from  Wiirzburg  after  a  political  exile  of  eight  years;  an  exile 
due  to  his  sympathy  with  the  revolutionary  tendencies  of  1848.  This 
laboratory  was  the  forerunner  of  the  many  which  have  been  founded  in 
the  past  fifty-five  years  in  all  parts  of  the  world,  and  which  have  been 
found  essential  not  only  for  the  purpose  of  teaching  and  research,  but 
also  in  the  modern  hospital.  And  again  of  importance  is  that  influence 
exerted  through  his  famous  pupils  such  as  Leyden,  v.  Eecklinghausen, 
Cohnheim,  Waldeyer,  Kiihne  and  Eindfleisch,  to  mention  only  the  more 
prominent,  who  carried  his  views  to  other  fields  and  continued  his 
methods.     Other  great  influences  were  to  extend  the  territory  of  pathol- 


28  MEDICAL    EE SEARCH   AND    EDUCATION 

ogj,  as,  for  examples,  Cohnheim's  conception  of  experimental  pathology, 
Weigert's  tinctorial  methods  for  the  differentiation  of  cells  and  tissues, 
Ehrlich's  application  of  these  methods  to  the  study  of  the  blood, 
Metchnikoff's  studies  in  comparative  pathology,  and  finally  the  science 
of  bacteriology;  but  with  Virchow  remains  the  credit  of  having  estab- 
lished pathology  as  a  science  of  university  rank. 

The  third  of  a  century  beginning  in  1828  with  the  founding  of 
Liebig's  laboratory  and  ending  in  1858  with  the  publication  of  Vir- 
chow^s  doctrine  of  cellular  pathology,  represents  a  greater  advance  in 
the  science  of  medicine  than  the  combined  activities  of  all  the  preceding 
centuries.  What  was  the  influence  of  these  advances  on  the  art  and 
practise  of  medicine?  Medicine  at  the  beginning  of  the  century  was 
still  influenced  by  the  metaphysical  treatment  of  scientific  subjects. 
The  previous  century  had  been  one  of  schools  and  systems,  those  of 
Cullen  and  Brown  in  England,  Broussais  in  France  and  Hoffman  and 
Stahl  in  Germany.  It  was  also  the  time  of  Hahnemann  (1753-1844) 
and  the  rise  of  homeopathy.  The  prevailing  tendency  was  to  base  dis- 
ease on  the  study  of  symptoms,  without  regard  to  the  underlying  patho- 
logical changes  causing  the  symptoms.  A  few  quotations  may  bring 
this  period  of  change  from  the  old  to  the  new  prominently  before  you. 

Helmholtz  writes  of  the  period  of  his  student  life : 

My  education  fell  within  a  period  of  the  development  of  modern  medicine 
when  among  thinking  and  conscientious  minds  there  reigned  perfect  despair. 
It  was  not  difficult  to  understand  that  the  older  and  mostly  theorizing  methods 
of  treating  medical  subjects  had  become  absolutely  useless.  .  .  .  We  can  not 
wonder  if  many  honest,  serious  thinking  men  turned  away  in  dissatisfaction 
from  medicine,  or  if  they  from  principle  embraced  an  extreme  empiricism. 

And  again  he  says : 

At  that  time  there  were  many  among  the  younger  doctors  who,  in  despair 
about  their  science,  gave  up  all  therapeutics,  and  took  to  empiricism. 

This  was  from  a  scientific  man,  who  had  much  to  do  with  the 
changes  about  to  come,  and  perhaps  somewhat  biased;  but  we  have  the 
view  of  Stieglitz,  an  "  old  and  learned  practitioner,"  expressed  in  1840 : 

German  medicine  was  sunk  so  low  and  is  so  emasculated  as  to  require  any 
sort  of  shaking  up.  Whatever  gives  it  a  new  direction  will  be  wholesome,  though 
new  errors  or  possibilities  may  result  therefrom. 

But,  to  continue  Helmholtz's  remarks : 

The  right  kind  of  work  brought  forth  its  fruits  much  sooner  than  many 
had  hoped.      The  introduction  of  mechanical  notions  into  the  theories  of  cir- 


SESEARCH    IN   MEDICINE  29 

culation  and  respiration,  a  better  insight  into  the  phenomena  of  heat,  the  more 
minutely  elaborated  physiology  of  the  nerves,  speedily  produced  practical  results 
of  the  greatest  importance;  the  microscopical  examination  of  parasitic  tissues, 
the  stupendous  development  of  pathological  anatomy,  led  irresistibly  from 
nebulous  theories  to  real  facts. 

As  Helmholtz  was  born  in  1821  his  point  of  view  is  that  of  one  who 
saw  both  the  old  and  the  new;  the  old  in  his  student  days,  the  new  as 
one  of  those  who  labored  to  bring  about  the  change.  His  view  is  largely 
that  of  the  scientist,  but  we  have  fortunately  the  reminiscences  of 
another,  a  practitioner  of  medicine,  who  labored  as  a  student  of  medi- 
cine in  those  days  of  rapid  change.  I  refer  to  Abraham  Jacobi,  our 
own  Jacobi,  "  the  father  of  pediatrics,"  who  studied,  as  he  tells  us  in 
his  McGill  address,  "  in  three  universities  from  1847  to  1851,  in  Griefs- 
wald,  Gottingen  and  Bonn."    Eef erring  to  this  period,  he  says : 

I  have  lived  under  the  eyes  of  and  contemporaneously  with  great  men  and 
during  the  development  of  modern  medicine  .  .  .  not  as  a  cooperator,  it  is  true, 
but  as  an  interested  looker-on,  when  great  things  happened. 

Aside  from  Vienna,  where  Eokitansky  taught,  there  were 

only  two  places  in  all  Germany  in  which  pathological  anatomy  could  be  learned. 
One  of  them  was  Wiirzburg,  there  was  Virchow,  the  other  was  Gottingen,  there 
was  Frerichs.  So  to  Gottingen  I  went  in  search  of  pathological  anatomy.  .  .  . 
At  the  same  time  I  looked  for  the  advantages  of  chemical  laboratory  work  under 
Wiggers  and  Wohler. 

Among  the  scientific  happenings  of  Jacobi's  first  medical  year 
(1847)  are  the  following:  Helmholtz's  address  on  the  conservation  of 
energy;  the  use  of  ether  anesthesia  in  obstetric  practise  by  Hamner 
and  in  dentistry  by  Delabarre  (first  used  by  Warren  at  Boston  in 
1846)  ;  Liebig's  researches  on  meats;  the  employment  of  prismatic 
glasses  by  Kreke  and  Bonders ;  the  first  use  of  chloroform  by  Simpson ; 
the  employment  by  Duchenne  of  faradization  in  the  treatment  of 
paralysis;  the  discovery  of  unstriped  muscle  fibers  by  Kolliker  and  the 
studies  by  Semmelweis  of  the  etiology  of  fever  in  puerperal  women. 

Among  the  events  of  the  next  five  years,  during  three  of  which  he 
was  a  student  and  two  a  political  prisoner,  Jacobi  mentions :  Bunsen's 
quantitative  analysis  of  urea,  the  founding  of  spectral  analysis,  the  use 
of  cold  for  anesthesia,  Claude  Bernard's  puncture  of  the  fourth  ventricle 
and  his  demonstration  of  the  glycogenic  function  of  the  liver  and  of  the 
vasomotor  nerves;  the  discovery  of  TricJiophyton  tonsurans  and  Balan- 
tidium  coli  by  Malmsten,  the  invention  of  the  spirometer  by  Hutchinson 
and  of  the  ophthalmoscope  by  Helmholtz,  and  the  sphygmograph  by 


30  MEDICAL   BESEABCH   AND    EDUCATION 

Vierordt.  Altogether  Jaeobi  tells  of  a  host  of  observations  made  in  a 
short  period  of  six  years.  And  the  list  is  not  one  of  laboratory  dis- 
coveries only.  It  includes  important  advances  in  clinical  medicine  and 
surgery,  as  Meigs's  discovery  of  the  importance  of  thrombosis  as  a  cause 
of  death  in  puerperal  women,  Marion  Sims's  vesico-vaginal  operation, 
Detmold's  operation  for  abscesses  of  the  cranial  cavity.  Walker's  work 
on  the  infectious  nature  of  secondary  syphilis,  Eomberg's  studies  of 
tabes  dorsalis,  Pravaz's  invention  of  subcutaneous  injection,  Kuchen- 
meister's  discovery  of  the  connection  between  taenia  and  the  scolex 
found  in  pork,  Bigelow's  resection  of  the  femur  and  Bennet's  work  on 
leucocythemia. 

More  could  be  quoted  from  Jacobi's  impression  of  this  period,  but 
this  is  enough  to  show  that  medicine  was  advancing  not  only  in  the 
laboratory,  but  in  the  clinic.  One  may,  as  Jaeobi  says,  "  recognize  in 
my  fragmentary  enumeration,  facts  of  crucial  import." 

These  advances  in  clinical  medicine  and  surgery  were  due  to  several 
factors;  to  the  increasing  use  of  the  methods  of  physics,  chemistry  and 
biology,  to  the  influence  of  pathology,  to  the  introduction  of  new 
procedures  in  diagnosis,  and  in  surgery,  to  the  facility  of  operation 
offered  by  anesthesia.  What  a  change  in  the  practise  of  medicine  these 
observations  and  applications  brought  about!  How  different  their 
influence  from  that  of  the  earlier  schools  and  systems  with  which  we 
associate  the  names  of  Brown,  Cullen,  Broussais,  Hoffman  and  Stahl ! 

Such  schools  and  systems,  while  of  interest  to  the  general  historian 
of  medicine,  offer  no  assistance  to  one  seeking  the  lines  of  advance 
dependent  on  investigation  or  research  in  medicine.  Fortunately  for 
the  history  of  clinical  medicine  the  systematists  did  not  occupy  the  field 
to  the  exclusion  of  those  guided  by  objective  observation,  for  we  find 
Sydenham  (1624-1689)  and  Boerhaeve  (1668-1738)  studying  disease 
unbiased  by  schools  or  systems,  and  applying  the  methods  of  close 
observation  which  we  now  recognize  as  those  of  modern  clinical  medi- 
cine. But  although  Sydenham  and  Boerhaeve  and  their  followers  aided 
progress  by  the  addition  of  some  positive  knowledge  to  clinical  medicine, 
their  influence  on  the  development  of  medicine  was  not  great,  for  they 
were  before  the  days  of  Morgagni,  Haller,  Hunter,  Bichat  and  Eoki- 
tansky  and  the  methods  associated  with  these  names.*     Without  patho- 

*  Before  and  about  the  time  of  the  period  so  represented,  some  of  the  impor- 
tant contributions  made  to  clinical  medicine  and  pathological  anatomy  were  as 


BESEARCH   IN   MEDICINE  31 

logical  anatomy  clinical  classification  was  impossible,  and  without 
physiology  and  the  methods  of  the  physiologist,  clinical  interpretation 
was  difficult.  The  influence  of  pathological  anatomy  on  clinical  medi- 
cine was  felt  first  in  England  through  Baillie  (1761-1823),  a  pupil  of 
Hunter;  in  France,  after  Bichat,  through  Louis,  Andral  and  Lsennec; 
in  Germany  through  Schonlein  and  Eomberg;  and  in  America  through 
the  pupils  of  Louis.  The  discovery  of  the  diseased  conditions  with 
which  we  associate  the  names  of  Bright,  Pott,  Addison,  Graves,  Stokes 
and  Hodgkins  came  at  this  time,  as  also  Marshall  Hall's  discrimination 
of  diseases  of  the  spinal  cord  and  Bayle's  study  of  tuberculosis  of  the 
lung.  It  was  the  period  when  the  best  members  of  the  profession 
endeavored  to  give  to  the  study  of  symptoms  the  same  precision  as 
characterized  anatomical  observation  and  to  combine  the  results  of  this 
method  with  the  revelations  of  pathological  anatomy.  It  was  this 
method  that  culminated  in  Louis's  so-called  "  numerical  or  statistical 
method,"  the  method  of  basing  conclusions  on  large  groups  of  records 
rather  than  on  isolated  observations,  and  which,  in  this  country,  through 
the  work  of  two  of  Louis's  students,  Gerhard  and  Stille,  led  to  the 
differentiation  of  typhoid  fever  from  typhus  fever,  with  which  it  had 
been  confounded. 

But  of  equal  importance  was  the  second  influence  which  was  at 
work,  that  of  improved  methods  of  diagnosis  of  diseases  of  the  heart 
and  lungs,  the  methods  of  percussion  and  auscultation.  Percussion 
was  first  used  by  Auenbrugger,  in  1761,  but  was  treated  with  contempt 
and  ridicule  until  1808  when  his  pamphlet  was  translated  into  French 
by  Corvisart,  who  proclaimed  the  value  of  the  method  and  obtained  for 
it  universal  recognition.  Shortly  after,  in  1819,  came  Lsennec's  work 
on  the  use  of  the  stethoscope  in  auscultation,  and  Skoda  in  1839  did 
much  to  extend  the  use  of  both  percussion  and  auscultation. 

This  phase  of  medicine,  the  development  of  instruments  and  means 
of  studying  diseases  of  the  internal  organs  and  the  organs  of  the  special 
senses — the  history  of  the  stethoscope,  the  ophthalmoscope,  the  laryngo- 
scope, and  like  instruments — is  a  most  fascinating  subject  and  one 
worthy  of  extended  treatment,  but  it  must  suffice  here  to  state  that  the 

follows:  aneurism  and  diseases  of  the  heart  by  Lancisi,  Albertini  and  Senac; 
an  investigation  by  Fothergill,  of  the  diseases  now  known  as  diphtheria  and  tic 
douloureux;  of  prison  and  camp  fevers  by  Pringle,  of  epidemic  fevers  by  Hux- 
ham;  of  diseases  of  the  skin  by  Willan,  of  angina  pectoris  by  Heberden,  and  of 
gastric  ulcer  by  Baillie. 


82  MEDICAL   BESEABCH   AND    EDUCATION 

new  methods  of  direct  exploration  brought  about  a  complete  revolution 
in  the  knowledge  of  disease  and  had  "  more  influence  on  the  develop- 
ment of  modem  medicine  than  all  the  '  systems '  evolved  by  the  most 
brilliant  intellects  of  the  eighteenth  century/'      (Payne.) 

Exact  clinical  observation,  the  study  of  pathological  anatomy  and 
the  increasing  use  of  instruments  and  methods  tending  to  accuracy  in 
diagnosis  were,  therefore,  the  characteristic  features  of  the  early  nine- 
teenth century  school  of  medicine.  Both  medicine  and  surgery  were 
developing  along  lines  which  ensured  accelerated  progress  under  the 
impetus  of  the  discoveries  in  bacteriology  which  were  soon  to  follow, 
and  we  could  with  propriety  pass  on  to  the  era  of  bacteriology,  if  it  were 
not  for  one  great  boon,  destined  to  have  an  enormous  influence  on  the 
practise  of  surgery,  on  the  diminution  of  human  suffering  and  on  the 
general  advance  of  research  in  medicine.  This  was  the  introduction  of 
anesthesia.  Surgery  had  steadily  advanced  in  technic,  resourcefulness 
and  daring,  but  the  torments  of  surgery  were  such  that  operations  were 
mainly  those  of  necessity.     As  Mumf ord  says : 

Surgical  pain  was  real  enough;  there  was  no  disguising  it.  The  terror  of 
operation  was  a  very  hell,  even  in  anticipation;  the  fact  itself  no  man  has  found 
words  to  describe.  The  shadow  of  it  has  lengthened  even  to  our  own  daj. 
Surgeons  as  well  as  patients  dreaded  the  knife. 

Eobert  Listen,  two  years  before  the  discovery  of  ether  congratulated 
his  students  that  the  "  field  of  operative  surgery  "  was  "  happily  nar- 
rowed."    Keen  writes : 

It  is  a  striking  commentary  on  the  immediate  results  of  anesthesia  to  learn 
that,  in  the  five  years  before  the  introduction  of  ether,  only  184  persons  were 
willing  to  submit  themselves  to  such  a  dreadful  ordeal  in  the  Massachusetts 
Hospital,  an  average  of  37  operations  per  annum,  or  3  per  month.  In  the  five 
years  immediately  succeeding  its  introduction,  although  the  old  horror  could  not 
be  overcome,  487  operations,  or  almost  100  annually,  were  performed  in  the  same 
hospital.  During  the  last  year  (1898)  in  the  same  hospital  3,700  operations 
were  performed. 

This  change  was  brought  about  in  1846,  when  W.  T.  G.  Morton,  an 
American  dentist,  by  publicly  administering  ether,  proved  to  the  world 
that  it  was  a  safe  and  sure  anesthetic.  The  operation  was  performed 
by  John  Collins  Warren  at  the  Massachusetts  General  Hospital  and  the 
names  anesthesia  and  anesthetic  were  suggested  by  Oliver  Wendell 
Holmes.  Anesthesia  was  therefore  essentially  a  Boston  affair  as  far 
as  its  introduction  to  the  world  was  concerned,  but  the  claims  of  its 
discovery  made  by  others    (Long,  Jackson,  Wells,  Marcy)   leave  the 


EESEAECH   IN   MEDICINE  33 

question  of  priority  in  the  knowledge  of  and  use  of  ether  in  much  con- 
fusion. With  this  phase  we  are  not  at  present  concerned.  One  year 
after  the  demonstration  in  Boston,  Simpson,  of  Edinburgh,  recom- 
mended chloroform  as  an  anesthetic  of  equal  value  with  ether.  Not 
only  surgery  but  obstetrics,  dentistry  and  the  various  specialties  bene- 
fited by  this  great  boon  of  anesthesia  and  within  a  year  the  administra- 
tion of  anesthetics  was  a  universal  practise  throughout  the  civilized 
world.  Surgery,  freed  of  its  horrors,  developed  along  lines  hitherto 
undreamed  of,  and  made  those  rapid  strides  which  prepared  it  for  the 
era  of  antisepsis  in  the  next  generation. 

The  next  lecture  will  concern  itself  with  the  story  of  Pasteur  and 
the  development  of  bacteriology  and  the  influence  of  the  latter  on 
medicine  and  surgery. 


LECTUEE   III 

Pasteur  and  the  Era  of  Bacteriology 

The  story  of  bacteriology  can  best  be  told  by  recounting  the  labors 
of  Pasteur,  for  while  bacteria  were  known  and  theories  of  infection 
had  been  elaborated  and  vaccination  practised  before  his  time,  it  was 
he  who  definitely  established  the  importance  of  bacteria  in  putrefaction, 
fermentation  and  disease,  and  gave  to  vaccination  a  scientific  basis. 
The  influence  of  these  labors  is  comparable  in  medicine  only  to  that  of 
Virchow  in  his  field  and  is  as  great  as  that  exerted  in  general  biology 
by  Darwin's  researches.  The  story  of  rapid  sequence  of  Pasteur^s 
brilliant  discoveries  in  science,  each  of  crucial  importance  and  estab- 
lishing a  new  principle  have,  I  believe,  no  parallel  in  biology  or,  for  that 
matter,  any  other  science. 

But  before  presenting  Pasteur's  labors  it  is  necessary  to  outline  the 
knowledge  of  bacteria  and  the  theories  of  fermentation,  infection  and 
allied  processes  which  were  current  at  the  beginning  of  his  era. 

Bacteria  were  first  seen  by  Leeuwenhoek,  a  Dutch  lens-maker  in 
1673.  This  was  long  before  the  day  of  the  compound  microscope,  but 
Leeuwenhoek  was  able  to  make  such  excellent  short  focus  single  lenses 
that  he  could  study  red  blood  corpuscles  and  spermatozoa,  detect  minute 
globular  particles  in  yeast,  and,  as  we  know  from  his  drawings,  even 
discover  some  of  the  larger  microorganisms  in  the  tartar  of  the  teeth, 

4 


34  MEDICAL  BESEASCH  AND  MEDICAL  EDUCATION 

in  saliva  and  intestinal  and  other  fluids.  In  1838,  about  the  time  of  the 
development  of  the  compound  microscope,  Ehrenberg  attempted  a 
classification  of  bacteria  based  on  sixteen  species.  Our  exact  knowl- 
edge, however,  begins  with  Cohn's  studies  which  extended  from  1853 
to  1875,  and  were  the  first  to  differentiate  between  the  spherical  forms 
which  we  call  cocci,  and  the  rod-like  forms  or  bacilli.  These  early 
studies  were  almost  exclusively  botanical  in  nature  and  it  was  not  until 
1873  that  Cohn  could  include  definite  disease-producing  bacteria  in  his 
classification  of  the  vegetable  microorganisms. 

Bacilli  had  been  found,  it  is  true,  as  early  as  1850  in  diseased  ani- 
mals, for  example,  the  anthrax  bacillus  in  animals  dying  of  splenic 
fever.  So  also  Schonlein  in  1839  had  discovered  a  vegetable  parasite,  a 
mycelial  form,  higher  than  the  bacteria,  in  the  disease  of  the  skin 
known  as  favus;  Malmsten  in  1848  had  found  a  somewhat  similar  form 
in  barber's  itch,  and  Bassi  about  1832  had  demonstrated  that  a  disease 
of  the  silkworm  was  due  to  a  minute  cryptogamic  plant.  But  the  im- 
portance of  these  observations  was  not  widely  appreciated  and  no  gen- 
eral relation  was  established  between  bacteria  and  disease  in  man. 

Likewise,  theories  of  infection  which  explained  disease  as  due  to 
invisible  microorganisms  had  been  propounded  as  early  as  1763,  as  for 
example  that  of  Plenciz,  which,  based  on  Leeuwenhoek's  discoveries, 
ascribed  to  every  disease  its  particular  microorganism,  explained  the 
decomposition  of  animal  and  vegetable  material  as  due  to  microorgan- 
isms, postulated  the  growth  of  bacteria  in  living  tissues  and  suggested 
the  possibility  of  the  transmission  of  disease  virus  by  the  air.  Such 
views,  naturally,  were  without  experimental  basis  and  without  even  an 
objective  knowledge  of  the  microorganisms  supposed  to  be  etiologically 
concerned.  In  other  words  the  propounder  of  this  theory,  as  others 
after  him,  believed  more  than  he  could  prove.  By  the  middle  of  the 
century,  however,  observations  on  bacteria,  largely  as  the  result  of  the 
labors  of  botanists,  were  accumulating,  and  views  about  spontaneous 
generation,  fermentation  and  infection  were  being  discussed,  but  the 
fundamental  experiments  necessary  to  settle  these  problems  were  yet 
to  be  made,  and,  curiously  enough,  it  was  a  chemist,  influenced  by 
the  methods  of  physics,  who  was  to  establish  bacteriology  as  a  biological 
science  and  to  give  to  it  the  important  place  in  medicine  which  it  has 
occupied  for  the  past  thirty  years. 

Pasteur  was  this  chemist,  and  his  first  great  discovery  was  in  crys- 


HESEASCn    IN    MEDICINE  ^^ 

tallography,  the  explanation  of  the  behavior  of  one  of  the  tartaric  acids 
to  polarized  light.  This  acid  obtained  from  the  lees  of  wine  was, 
unlike  other  acids  of  the  group,  inactive  to  polarized  light.  This 
inactivity  Pasteur  demonstrated  to  be  due  to  the  fact  that  it  was 
made  up  of  two  isomeric  constituents.  The  crystals  of  one  of  these 
constituents  bore  hemihedral  facets  on  the  right  side  and  rotated  the 
plane  of  polarized  light  to  the  right,  and  those  of  the  other  bore 
similar  facets  on  the  left,  and  therefore,  rotated  to  the  left,  but,  as 
Pasteur  found,  when  combined,  these  crystals  did  not  rotate  the  plane 
of  polarized  light  at  all.  This,  the  first  of  his  discoveries,  was  in  1848, 
the  year  that  Virchow  was  investigating  typhus  fever  in  Silesia.  If  it 
is  necessary  to  fix  contemporary  events  more  definitely  I  may  introduce 
the  fact  that  two  years  later  Pasteur  quotes  Professor  Biot  as  referring 
to  his  recent  discoveries  in  crystallography  as  "  a  very  California." 

Now,  this  work  of  Pasteur  on  the  tartaric  acids  not  only  opened  a 
new  field  in  crystallographic  studies,  but,  of  far  greater  importance, 
led  to  the  discoverer's  studies  in  fermentation.  In  the  course  of  his 
work  on  the  tartaric  acids  he  found  that  if  salts  of  the  inactive  acid 
were  acted  upon  by  a  mould  {Penicilium  glaucum)  the  right-handed 
constituent  was  destroyed,  but  the  left-handed  remained  unchanged; 
and  from  this  he  concluded  that  the  change  from  an  optically  inactive 
to  an  optically  active  fluid,  under  such  experimental  conditions,  could 
be  due  only  to  the  presence  of  living  matter  causing  the  destruction  of 
one  component.  This  was  the  beginning  of  his  studies  of  fermentation, 
and  from  this  time  his  labors  were  those  which  eventually  established 
the  sciences  of  bacteriology  and  immunity. 

The  opportunity  to  study  alcoholic  fermentation  came  at  Lille  in 
1854,  at  a  time  when  Pasteur  was  professor  of  chemistry  and  dean  to 
the  faculty  at  that  place.  The  manufacturers  of  the  region  had  met 
with  disappointment  in  the  making  of  alcohol  from  beets,  and  one  of 
them  came  to  the  new  professor  of  chemistry  for  advice.  Pasteur 
undertook  daily  visits  to  the  factory  and  from  these  visits  came  the 
idea  of  studying  the  fermenting  beet  juice  in  the  laboratory. 

Fermentation,  at  the  time  Pasteur  entered  the  field,  was  a  subject 
involved  in  great  obscurity,  with  only  here  and  there  a  ray  of  light. 
Cagnaird-Latour,  in  1836,  had  studied  that  ferment  of  beer  called  yeast, 
and  had  observed  that  it  was  composed  of  cells  "  susceptible  of  repro- 
duction by  a  sort  of  budding,  and  probably  acting  on  sugar  through 


36  MEDICAL   SESEABCE   AND    EDUCATION 

some  effect  of  their  vegetation."  Schwann  and  Kiitzing  a  few  years 
later  reached  the  same  conclusion,  but  were  opposed  at  once  by  Liebig, 
who  enunciated  a  theory  of  mechanical  decomposition  and  denied  in 
its  entirety  the  theory  that  fermentation  was  a  biological  process.  Also 
Berzelius,  second  only  to  Liebig  as  an  authority,  believed  fermentation 
was  due  to  contact,  and  elaborated  a  theory  of  catalytic  force.  With 
such  weighty  opposing  opinion  the  observations  of  Cagnaird-Latour  and 
Kiitzing  were  neglected  and  fermentation  was  regarded  by  all  as  a 
strange  and  obscure  process  and  was  so  characterized  by  Claude  Ber- 
nard in  1850. 

Uninfluenced  by  these  views,  however,  Pasteur,  having  recognized 
that  living  matter  is  essential  for  alcoholic  fermentation,  adhered 
strictly  to  the  experimental  method,  and  taking  up  the  problem  of  lactic 
acid  fermentation  (the  souring  of  milk),  discovered  that  the  same 
budding  and  multiplying  of  a  cell  went  on  in  it  as  in  alcoholic  fermen- 
tation, but  that  the  cell  of  lactic  acid  fermentation  was  different  from 
that  of  alcoholic  fermentation.  He  observed  also  that  the  form  of  the 
cells  changed  according  to  the  conditions  of  fermentation.  Incidentally 
he  demonstrated  in  alcoholic  fermentation,  the  formation  of  glycerin 
and  succinic  acid  in  addition  to  the  well-known  products  alcohol  and 
carbonic  acid.  In  short,  the  outcome  was  that  Pasteur  completely 
demonstrated  that  the  fermentations  which  lead  to  the  production  of 
alcohol,  vinegar,  lactic  acid  and  butyric  acid  are  all  due  to  the  presence 
and  growth  of  minute  organisms,  or,  in  his  own  words,  "  The  chemical 
act  of  fermentation  is  essentially  a  correlative  phenomenon  of  a  vital 
act  beginning  and  ending  with  it." 

The  demonstration  of  the  part  played  by  specific  microorganisms  in 
the  different  fermentations  was,  as  may  readily  be  seen,  suggestive  of 
the  etiology  of  infectious  diseases.  It  was  in  the  midst  of  these  labors 
that  the  Academic  des  Sciences  conferred  upon  Pasteur  the  Prize  for 
Experimental  Physiology  (for  1859),  and  it  was  Claude  Bernard  who 
drew  up  the  report  and  dwelt  upon  the  "  physiological  tendency  in 
Pasteur's  researches."  Ten  years  before,  Bernard  had  characterized 
the  process  of  fermentation  as  "  obscure." 

The  results  of  the  investigation  of  fermentation  led  naturally  to  a 
debate  among  the  academicians  concerning  spontaneous  generation, 
and  in  this  dispute  Pasteur  took  a  most  important  part.  The  older 
examples  of  spontaneous  generation,  as,  for  example,  the  development 


BESEAECH   IN   MEDICINE  37 

of  mice  from  a  mixture  of  soiled  linen  and  cheese  and  of  maggots  from 
decomposing  meat,  had  long  been  discarded,  but  the  demonstration 
that  fermentation  and  putrefaction  were  due  to  microscopic  living  or- 
ganisms raised  the  question:  Whence  comes  this  microscopic  life?  Do 
or  do  not  these  bodies  arise  spontaneously  in  putrescible  and  ferment- 
able fluids?  The  results  of  several  investigations  were  already  at 
hand.  Thus  Spallanzani  (1769)  had  shown  that  if  a  putrescible  fluid 
was  hermetically  sealed  in  flasks  and  the  flasks  heated  in  boiling  water, 
decomposition  did  not  occur;  Schulze  (1836)  had  obtained  the  same 
result  by  filtering  through  strong  solutions  of  acids  and  alkalies  the  air 
which  entered  such  flasks,  as  had  also  Schwann  (1837),  by  first  pass- 
ing the  air  through  heated  tubes;  and  likewise  Schroeder  and  Dusch 
(1854)  by  filtering  the  air  through  cotton  plugs.  All  these  procedures 
robbed  the  air  of  the  suspended  microorganisms  and,  as  the  fluids  had 
previously  been  sterilized  by  heat,  decomposition  did  not  occur.  But 
at  the  time  these  procedures,  though  now  recognized  as  the  basic  prin- 
ciples of  bacteriological  technic,  as  applied  to  sterilization  and  asepsis, 
did  not  gain  general  credence.  "  Philosophic  argumentation  always  re- 
turned to  the  fore."  The  theory  of  spontaneous  generation  would  not 
down,  and  from  1858  to  1862  it  was  the  most  important  matter  of  de- 
bate in  the  discussions  of  the  Academic  des  Sciences. 

Pouchet  and  Pasteur  were  the  disputants,  the  former  defending  the 
thesis  that  "  animals  and  plants  could  be  generated  in  a  medium  abso- 
lutely free  from  atmospheric  air,  and  into  which,  therefore,  no  germ  or 
organic  bodies  could  have  been  brought  by  the  air  " ;  the  latter  insisting 
that  only  through  the  entrance  of  such  living  organisms  could  the 
changes  in  question  take  place.  The  discussion  lasted  several  years, 
and  to-day  presents  many  interesting  details,  but  it  may  suffice  to  state 
that  it  was  ended  by  Pasteur's  demonstration  that  if  the  neck  of  a  flask 
was  drawn  out  into  a  fine  tube  and  bent  into  a  double  curve  and  the 
flask  then  heated  by  boiling,  no  decomposition  occurred.  The  flask  was 
open  to  the  atmospheric  air,  but  the  microorganisms  of  the  air  were 
arrested  by  the  drop  of  water  of  condensation,  in  the  lower  point  of  the 
curved  neck.  This  demonstration,  with  the  later  work  of  Cohn  on 
spores  and  of  Tyndall  on  floating  matter  in  the  air,  disposed  of  the 
doctrine  of  spontaneous  generation  and  led  to  the  universal  acceptance 
of  Harvey's  law  Omne  vivum  ex  ovo,  or  as  it  was  modified,  Omne 
vivum  ex  vivo. 


38  MEDICAL   BESEABCE    AND    EDUCATION 

It  is  not  surprising  that  Pasteur  at  this  time  foresaw  the  possibili- 
ties ia  the  study  of  the  etiology  of  the  infectious  diseases.  The  process 
of  fermentation,  due  to  living  microorganisms,  and  beginning  with  a 
period  of  apparent  inactivity,  passing  on  to  a  stage  of  very  evident  ac- 
tivity and  finally  sinking  gradually  into  quiescence,  was  analogous  to 
the  period  of  incubation,  the  stage  of  active  manifestations  and  the 
gradual  defervescence  of  an  infectious  disease.  Also  the  specificity  of 
the  ferments  was  evidently  suggestive  of  the  specific  etiology  of  dis- 
ease, and  altogether  we  see  from  several  of  Pasteur's  statements  at  this 
time  that  the  relation  of  microscopic  organisms  to  disease  occupied  his 
mind.  Thus  in  a  letter  to  his  father,  in  1860,  he  expressed  the  hope 
that  he  may,  "bring  a  little  stone  to  the  frail  and  ill-assured  edifice  of 
our  knowledge  of  those  deep  mysteries  of  Life  and  Death  where  all  our 
intellects  have  so  lamentably  failed  "  and  in  1863,  after  an  audience 
with  Napoleon  III.,  he  writes,  "  I  assured  the  Emperor  that  all  my  am- 
bition was  to  arrive  at  the  knowledge  of  the  causes  of  putrid  and  con- 
tagious diseases." 

And  now  with  that  peculiar  trick  of  coincidence  that  is  so  surprising 
in  the  course  of  culture  and  inquiry,  we  find  that  about  this  time  bac- 
teriology began  to  make  advances  along  three  general  lines  of  study: 
(1)  The  etiology  of  the  acute  infectious  diseases;  (2)  the  prevention 
of  infection,  and  (3)  the  achievement  of  cure  or  immunity  by  vaccina- 
tion. In  the  first  and  third  of  these,  Pasteur  played  a  prominent  part 
and  it  was  his  work  on  fermentation  which  suggested  the  second  to 
Lister.  Pasteur's  entrance  into  the  field  of  etiology  and  the  results  he 
there  accomplished  form  one  of  the  most  interesting  phases  of  the  his- 
tory of  science  and  its  outcome,  a  matter  of  the  greatest  economic  im- 
portance to  France.  The  opportunity  to  study  an  infectious  disease 
was  offered  by  an  epidemic  of  a  mysterious  disease  which  was  ruining 
the  silkworm  industry.  Whence  the  disease  came  or  how  it  was  con- 
tracted no  one  knew.  Its  onset  was  recognized  only  by  the  presence 
of  the  little  brown  or  blackish  spot  from  which  it  got  its  name  (pe- 
brine).  Pasteur,  who  undertook  the  investigation  at  the  request  of  his 
old  master  Dumas,  now  a  senator,  knew  nothing  of  the  industry  and,  as 
he  wrote  Dumas,  "  had  never  touched  a  silkworm."  But  under  pressure 
of  Dumas's  solicitation  he  finally  yielded,  and  found  himself,  a  chem- 
ist, hitherto  interested  chiefly  in  the  study  of  crystallography  and  fer- 
mentation, thrown  at  once  into  a  new  and  strange  field.     That  his  re- 


MESEAECH    IN   MEDICINE  39 

suits  were  due  largely  to  the  training  and  the  point  of  view  obtained 
through  the  study  of  fermentation  and  the  use  of  the  microscope,  there 
can  be  little  doubt,  and  one  is  inclined  to  apply  to  Pasteur  at  this  stage 
of  his  work  his  own  statement  of  ten  years  before;  "in  the  fields  of 
observation,  chance  favors  only  the  mind  which  is  prepared." 

Once  in  the  silkworm  country  he  applied  himself  energetically  to 
the  study  of  the  "  fatal  spots."  The  story  of  the  complete  investigation 
is  a  long  one,  but  the  main  points  are  that  within  a  month  he  found 
that  although  worms,  moths  and  eggs  were  infected,  the  critical  stage 
was  the  infection  of  the  moths,  and  that,  in  these,  the  infection  could 
be  readily  demonstrated  with  the  aid  of  the  microscope,  and,  that  hav- 
ing demonstrated  this,  the  remedy  lay  in  using  the  eggs  of  non-in- 
fected moths  only.  Thus  a  new  breed  of  worms  free  from  infection 
could  be  obtained  and  the  extension  of  the  disease  arrested.  In  the 
course  of  this  work  he  reproduced  the  disease  experimentally  by  feeding 
healthy  moths  with  infected  mulberry  leaves,  a  novel  procedure  then, 
but  one,  which,  with  its  modifications,  was  soon  to  become  a  common- 
place principle  of  bacteriological  investigation.  The  investigation  of 
the  silkworm  problem  lasted  for  five  years,  or  until  Pasteur  cleared  up 
not  only  the  difficulties  connected  with  pebrine,  a  disease  due  to  infec- 
tion with  a  psorosperm,  but  unmasked  also  a  second  disease  of  the  silk- 
worm (flacherie),  a  bacterial  infection  of  intestinal  origin. 

In  the  meantime  Pasteur  continued  his  studies  of  the  diseases  of 
wines  (sour,  bitter  and  muddy  wines)  and  invented  the  process  known 
then  and  now  as  "  pasteurization."  This  was  the  simple  process  of  heat- 
ing the  wine  in  order  to  free  it  of  all  germs  of  wine  disease  and  make 
it  suitable  for  storage  and  exportation.  In  this  connection  he  expresses 
the  greatest  satisfaction  that  he  was  thus  able  to  contribute  to  the 
national  riches  through  the  practical  application  of  his  observations. 
In  1867  he  said : 

Nothing  is  more  agreeable  to  a  man  who  has  made  science  his  career  than  to 
increase  the  number  of  discoveries,  but  his  cup  of  J07  is  full  when  the  result  of 
his  observations  is  put  to  immediate  practical  test. 

The  term,  pasteurization,  is  now  most  frequently  heard  in  con- 
nection with  milk,  but  when  it  is  recalled  that  all  commercial  and 
domestic  methods  of  canning  and  preserving  solid  and  fluid  foods  are 
based  on  the  laboratory  experiments  of  Pasteur  one  obtains  an  adequate 
idea  of  the  importance  of  his  observations  and  likewise  appreciates  his 
satisfaction  at  the  practical  application  of  his  methods. 


40  MEDICAL   BESEABCH   AND    EDUCATION 

As  the  silkworm  problem  began  to  clear  up,  Pasteur's  thoughts 
turned  more  and  more  to  the  etiology  of  the  acute  infectious  diseases  of 
man  and  animals  and  their  experimental  study.  This  is  shown  in  his 
appeal  to  the  government  (1867)  for  a  laboratory.  In  this  appeal  he 
refers  to  the  advisability  of  investigating  splenic  fever  and  asks.  "  How 
can  researches  be  attempted  on  gangrene,  virus  or  inoculations,  with- 
out a  building  suitable  for  the  housing  of  animals?"  and  in  1871,  in  his 
book  on  beer,  with  the  diseases  of  which  he  had  busied  himself,  we  again 
find  a  reference  to  the  possibility  of  the  disease  of  man  and  animals 
being  due  to  microorganisms.  Here  again  it  is  evident  that  he  was 
influenced  by  the  idea  of  microorganisms  invisibly  introduced  into  fer- 
mentable fluids,  for  in  this  connection  he  says,  "  it  is  impossible  not  to 
be  pursued  by  the  thought  that  similar  acts  may,  must,  take  place  in 
animals  and  in  man  " ;  but  without  experimental  proof  he  refused  to  go 
further. 

Pasteur's  attack  on  animal  diseases  was,  however,  delayed,  first  by  a 
cerebral  hemorrhage  in  1868  which  left  him  partly  paralyzed,  and  then 
by  the  Franco-Prussian  war  which  interrupted  all  scientific  efforts  in 
Paris. 

Here  it  is  well  to  pause  a  moment  to  consider  the  attitude  of  the 
medical  profession  towards  the  theory  which  was  beginning  to  take 
shape  as  the  "  germ  theory."  The  following  decade  was  to  see  the 
bacterial  etiology  of  several  important  diseases  established.  Lister's 
practise  of  antisepsis  in  surgery  quite  generally  accepted,  and  the 
principle  of  specific  vaccine  treatment  demonstrated.  To-day  no  phase 
of  medicine  is  so  well  understood  by  the  world  at  large  as  that  of 
bacteriological  principles  and  aims.  Germs  and  sera,  prophylaxis  and 
quarantine,  antisepsis  and  pasteurization,  are  matters  of  common  knowl- 
edge and  of  ordinary  conversation,  but  it  is  difficult  for  one  unfamiliar 
with  pre-bacteriology  days  to  appreciate  the  views  which  had  to  be 
combated  only  forty  years  ago.  A  brief  glance  at  the  conditions  in  1873 
may  therefore  give  you  a  better  appreciation  of  the  events  of  the  suc- 
ceeding decade.  If  it  is  necessary  to  fix  the  period,  let  me  remind  you 
that  1873  was  the  year  the  University  of  California  removed  to  its 
present  site. 

The  Franco-Prussian  war  had  come  to  a  close.  Surgeons  remem- 
bered that  though  soldiers  were  killed  in  battle  by  tens  and  hundreds, 
they  died  of  surgical  diseases  by  thousands. 


EESEABCR    IN    MEDICINE  41 

In  the  hospitals  surgical  sepsis  ran  rampant.  Secondary  hemorrhage,  erysip- 
elas, pyemia  and  ' '  hospital  gangrene ' '  were  endemic.  Sometimes  wards,  wings 
or  whole  institutions  were  closed  in  vain  attempts  to  stamp  out  these  disorders. 
(Mumford.) 

The  causes  were  unknown  and  the  remedies,  therefore,  not  at  hand. 
Of  this  period  we  read  with  amazement  that 

Sometimes  a  surgeon  would  wear  the  same  old  operating  coat  for  years,  and 
would  pick  waxed  ligatures  from  the  button  hole  of  his  assistant  who  carried 
them  there  for  the  convenience  of  his  chief.     (Mumford.) 

To-day,  we  refer  to  it  as  "a  barbarous  era,"  but  before  Lister  the 
most  conscientious  surgeon  had  no  reason  to  do  otherwise  than  has  been 
described. 

And,  likewise,  internal  medicine,  although  it  had  benefited  by  im- 
provements in  the  methods  of  physical  diagnosis  and  by  the  application 
of  the  principles  of  pathological  anatomy,  had  made  no  progress  in  the 
prevention  and  treatment  of  the  infectious  diseases.  In  the  presence  of 
these  scourges  of  humanity  the  physician  was  not  only  helpless,  but 
indifferent  to  the  occasional  illuminating  discoveries  of  the  exact 
thinker  or  investigator.  Many  examples  of  this  indifference  are  at 
hand.  In  the  writings  of  Henle  (1840-1853)  was  announced  a  rational 
theory  of  infection,  but  it  was  ignored.  Oliver  Wendell  Holmes  (1843 
and  1855)  had  brought  forth  a  great  body  of  facts  indicating  that 
puerperal  fever  was  "  so  far  contagious  as  to  be  carried  from  patient 
to  patient  by  physicians  and  nurses,"  and  Semmelweis  in  1847,  working 
in  the  old  Vienna  hospital,  had  asserted  that  the  mortality  from  this 
disease  could  be  reduced  from  12  and  16  per  cent,  to  3  per  cent,  (later 
he  reduced  it  to  less  than  1  per  cent.)  by  the  simple  procedure  of 
cleansing,  in  a  solution  of  chlorinated  lime  water,  the  hands  of  those 
concerned  in  obstetrical  work.  The  views  of  Holmes  and  Semmelweis, 
however,  were  ridiculed  and  the  simple  antiseptic  procedure  of  the  latter 
was  not  continued,  and  when  Villemin,  thirteen  years  before  Koch  dis- 
covered the  tubercle  bacilli,  demonstrated  by  exact  experimentation  the 
transmission  of  tuberculosis  to  animals,  and  announced  that  the  dis- 
ease was  a  specific  transmissible  disease,  "  he  was  treated  almost  as  a 
perturber  of  medical  order."  I  know  of  nothing  which  so  clearly  shows 
the  state  of  mind  of  the  profession  of  that  day  as  the  remark  of  Pidoux 
in  criticizing  Villemin's  work.  Eeferring  to  the  doctrines  of  specificity 
he  says, 

These  doctrines  condemn  us  to  the  research  of  specific  remedies  or  vaccinetj 
and  all  progress  is  arrested.  .  .  .  Specificity  immobilizes  medicine. 


42  MEDICAL  BESEABCH  AND   EDUCATION 

This  representative  of  traditional  medicine  could  see  no  relation 
between  Villemin's  experiments  in  which  guinea  pigs  were  brought  into 
contact  with  the  dried  sputum  of  tuberculous  patients  and  Pasteur's 
theory  of  germs  floating  in  the  air  being  responsible  for  the  various 
fermentations. 

So,  likewise,  it  was  with  Davaine's  demonstration  (1863)  of  bacteria 
in  the  blood  of  animals  dying  with  anthrax.  His  view  that  these  micro- 
organisms, multiplying  rapidly  in  the  blood,  were  in  their  action  analo- 
gous to  Pasteur's  ferments  and  responsible  for  the  death  of  the  animal, 
was  received  only  with  arguments  and  did  not  immediately  stimulate 
investigation,  despite  his  proof  of  experimental  production  of  the 
disease  by  inoculation.  To  us,  who  know  to-day  the  fruits  of  the  study 
of  specific  etiology  and  specific  therapy,  the  opposition  to  the  views  of 
Villemin  and  Davaine  and  others  is  almost  incomprehensible,  but  it  must 
be  remembered  that  these  views  were  the  fruits  of  a  new  type  of  investi- 
gation in  practical  medicine,  that  of  laboratory  research  which  came 
close  to  the  sacred  precincts  of  the  clinic.  "  This  was  the  time,"  in 
France  at  least,  "  when  the  *  princes  of  science '  or  those  who  were  con- 
sidered as  such,  were  chiefly  physicians.  The  almost  daily  habit  of 
advising  and  counselling  "  gave  them  a  haughty  superiority,  and  views 
not  based  on  clinical  researches  were  set  aside  as  unsound.  Physiology 
and  chemistry  applied  to  the  normal  individual  were  well  enough,  and 
pathological  anatomy  with  the  post-mortem  room  as  an  adjunct  to  the 
clinic  was  very  proper,  but  for  the  laboratory  investigator  to  invade 
the  clinic  and  present  his  views  concerning  the  cause  of  disease  or  to 
explain  its  phenomena  was  another  matter.  A  well-known  surgeon  of 
that  time  stated: 

Laboratory  results  should  be  brought  out  in  a  circumspect,  modest  and 
reserved  manner,  as  long  as  they  have  not  been  sanctioned  by  long  clinical 
researches. 

But  at  the  very  time  (1873)  of  this  statement,  the  forces  which 
were  to  make  the  era  of  laboratory  research  the  greatest  of  medical  eras 
were  already  at  work;  Hoppe-Seyler  was  establishing  (1872)  the  first 
laboratory  of  physiological  chemistry,  v.  Eecklinghausen  was  studying 
the  wanderings  of  the  white  blood  cell,  "Weigert  was  staining  bacteria 
with  carmine,  Ehrlich  was  applying  dyes  to  the  study  of  the  cells  of  the 
blood  (both  later  developed  the  use  of  the  aniline  dyes  in  histological 
and  bacteriological  technic).  Abbe  was  developing  his  condensing  system 


BESEAECH    IN    MEDICINE 


43 


of  illumination  for  the  microscope,  Cohn  was  classifying  bacteria  ac- 
cording to  their  morphology,  Klebs  was  separating  bacteria  from  their 
culture  fluid  by  filtration  through  animal  cells,  Pettenkoffer  was  study- 
ing the  relation  of  water  to  epidemics  of  typhoid  fever  and  cholera, 
Obermeier  had  found  a  parasite  in  the  blood  of  relapsing  fever,  and 
Koch,  a  country  physician,  was  carrying  on  those  early  researches  which 
were  soon  to  make  him  the  leader  in  the  science  of  bacteriolog}'.  At 
the  same  time  (since  1866),  pathologists  (Eindfleish,  v.  Eeckling- 
hausen,  Waldeyer,  Birch-Hirschfeld  and  Klebs)  had  been  examining 
individuals  dying  of  septicemia,  pyemia,  erysipelas,  abscess,  inflamed 
wounds,  etc.,  and  had  found  bacteria  in  all  these  lesions,  Birch- 
Hirschfeld,  moreover,  had  called  attention  to  the  resembhnce,  in 
pyemia,  between  the  bacteria  of  the  local  lesion  and  those  in  the  internal 
organs,  and  had  observed  bacteria  within  the  leucocyte.  To  us,  who 
view  these  activities  in  retrospect,  they  are  phases  of  a  general  advance, 
the  culmination  of  which  is  common  knowledge,  but  in  the  early 
seventies  they  were  merely  the  non-related  efforts  of  individual  workers. 
Some  practical  demonstration  was  necessary  to  give  to  the  newer  type 
of  laboratory  work  an  importance  which  would  impress  the  profession. 
Such  a  demonstration  came  through  Lister's  antiseptic  treatment  of 
wounds  and  was  followed  shortly  by  the  observations  of  Koch  on 
anthrax,  and  of  Pasteur  on  vaccination  against  bacterial  disease. 

Lister's  first  publication  concerning  his  treatment  of  wounds  was 
in  1867,  but  it  was  not  until  the  late  seventies  that  his  views  were  quite 
generally  accepted.  In  the  meantime  his  methods  and  their  results 
served  to  concentrate  attention  on  bacteria  and  their  relation  to  the 
diseases  of  man.  He  regarded  wound  infection  as  putrefaction  due  to 
the  invasion  of  the  wound  by  minute  microorganisms  of  the  air;  a 
conception  which,  as  he  acknowledges  in  his  first  publication,  was  sug- 
gested by  Pasteur's  work  on  fermentation.  In  a  letter  to  Pasteur  in 
1874  he  offers  "  most  cordial  thanks  for  having  demonstrated  to  me  the 
germ  theory  of  putrefaction,  and  thus  furnished  me  with  the  principle 
upon  which  alone  the  antiseptic  treatment  can  be  carried  out." 

His  method  was  to  combat  this  air-borne  infection  with  an  anti- 
septic— carbolic  acid.  He  cleaned  a  wound  by  wiping  it  out  with  car- 
bolic acid  and  then  sealed  it  with  lint  soaked  in  this  acid.  All  instru- 
ments, sponges  and  dressings  coming  in  contact  with  the  wound  or  the 
hands  of  the  operator  or  assistants,  as  well  as  the  site  of  operation,  were 


44  MEDICAL   BESEABCH   AND   EDUCATION 

cleansed  in  the  same  way.  Also,  by  means  of  a  vaporizer,  carbolic  acid 
was  sprayed  into  the  atmosphere  about  the  site  of  operation.  As  years 
passed  the  details  of  this  method  changed.  We  now  speak  of  the 
suppuration  of  wounds,  not  of  putrefaction ;  the  carbolic  spray  has  been 
abandoned  and  our  ideas  about  sepsis  have  been  modified  in  several 
ways,  but  the  principle  remains  as  Lister  conceived  it.  The  beneficial 
results  of  this  new  treatment  in  Lister's  hands  were  immediate,  but  its 
general  application  came  slowly.  We  find  Pasteur  in  1874  referring  to 
Lister's  "  marvellous  surgical  methods  "  and  recommending  to  the  sur- 
geons of  Paris  the  use  of  instruments  and  dressings  sterilized  by  heat. 
The  complete  acceptance  of  Lister's  principle  would  appear  to  corre- 
spond to  the  year  1883,  when  he  was  made  a  baronet. 

The  benefits  of  antisepsis  are  now  so  familiar  to  us,  and  its  use  so 
much  a  matter  of  routine,  that  we  cease  to  wonder  at  the  revolution  it 
brought  about  in  surgery.  Some  diseases,  as  hospital  gangrene,  it  has 
abolished  entirely ;  others,  as  the  septic  surgical  diseases  of  former  days, 
have  been  reduced  almost  to  nil;  it  has  robbed  the  period  of  child-bearing 
of  one  of  its  chief  perils,  and  has  opened  to  surgery  regions  and 
cavities  of  the  body  previously  closed  on  account  of  the  great  mortality 
due  to  sepsis.  Antisepsis  shares  with  anesthesia,  as  its  discoverer. 
Lister,  shares  with  Morton,  Warren  and  Simpson,  the  honor  of  the 
great  advances  surgery  has  made  in  the  treatment  of  disease  and 
injuries  of  the  abdomen,  thorax  and  the  cranial  cavity.  Who  can  com- 
pute the  relief  from  suffering  and  the  saving  of  life  which  may  be 
traced  through  Lister  to  Pasteur's  laboratory  experiments  on  fermen- 
tation ? 

The  recognition  of  the  principle  of  asepsis  by  the  surgeons  was, 
then,  as  we  have  seen,  slow  and  grudging  enough ;  among  the  profession 
at  large  the  theory  of  infection  as  applied  to  acute  diseases  gained  more 
slowly  still.  It  was  not  until  1880  that  advance  in  the  knowledge  of 
the  bacterial  etiology  of  infectious  diseases  assumed  such  definite  shape 
as  to  attract  general  attention.  As  we  look  back  upon  this  early  work 
we  see  clearly  that  one  reason  for  this  slow  advance  was  the  absence  of 
proper  methods  of  isolating  bacteria  in  what  we  now  call  pure  cultures. 
Pasteur  and  his  co-laborers  made  (1)  direct  search  for  bacteria  in  the 
secretions,  blood  or  tissue  juices,  or  (2)  inoculated  fluid  media  or 
animals  with  such  material.  By  the  first  of  these  methods  it  was 
possible  to  recognize  bacteria  if  they  were  especially  abundant,  as  in 


BESEABCH    IN   MEDICINE  45 

anthrax,  and  it  was  by  this  method  that  Neisser  discovered  the  gono- 
coccus  (1879)  and  Hansen  the  leprosy  bacillus  (1879),  bacteria  which 
are  particularly  abundant  in  the  local  lesions  of  the  respective  diseases. 
The  second  method,  the  use  of  fluid  media,  was  satisfactory  if  the  mate- 
rial for  study  contained  only  one  type  of  organism ;  if  more  than  one  it 
was  obviously  difficult  to  study  the  life  history  of  a  bacterium  or  to 
obtain  exact  results  by  the  inoculation  on  account  of  the  simultaneous 
growth  of  associated  or  contaminating  organisms.  This  difficulty  was 
overcome  by  Koch,  in  1881,  through  the  introduction  of  solid  culture 
media.  Koch  had  already,  while  a  country  practitioner,  definitely  and 
clearly  established  the  relation  of  the  anthrax  bacillus  to  the  splenic 
fever  of  cattle  and  had  demonstrated  in  this  organism  the  formation  of 
spores  and  their  importance;  also  he  had  published  most  important 
observations  on  the  bacteriology  of  wound  infection.  The  use  of  solid 
media,  which  it  is  said  was  suggested  to  Koch  by  the  growth  of  mould 
on  potato,  led  at  once  to  rapid  advance,  for  as  each  bacterium  placed 
on  a  solid  medium  causes,  as  it  multiplies,  the  growth  of  a  visible 
colony,  it  was  possible  to  distinguish  colonies  having  different  char- 
acteristics and  by  transplantation  to  secure  pure  cultures.  The  demon- 
stration of  Koch's  solid  media  and  plate  method  at  the  Congress  of 
Hygiene  in  London  in  1881  caused  Pasteur  to  exclaim  "  C'est  un  grand- 
progres."  This  advance  and  the  use  of  microscopes  equipped  with  the 
oil  immersion  lens  and  the  Abbe  condenser,  and  the  increased  knowl- 
edge concerning  the  use  of  the  aniline  dyes  for  staining  purposes  gave 
to  bacteriology  the  technic  necessary  for  its  rapid  development. 
Koch  was  called  to  the  Imperial  Board  of  Health  in  Berlin  in  1880, 
and  started  the  first  laboratory  founded  for  the  study  of  bacteriology 
and  public  health  problems.  In  this  laboratory,  methods  of  studying 
and  photographing  bacteria  were  developed,  methods  of  disinfection 
based  on  the  knowledge  of  spore  resistance  were  elaborated,  and  the 
study  of  the  bacteriology  of  individual  diseases  inaugurated.  As  a  result 
of  the  latter  activity,  he  announced,  in  1882,  the  discovery  of  the 
bacillus  of  tuberculosis,  and  it  is  not  too  much  to  say  that  his  announce- 
ment astounded  and  profoundly  stirred  the  entire  civilized  world.  In 
the  same  year  Lbffler  and  Shiitz  announced  the  discovery  of  the  bacillus 
of  glanders,  and  Pasteur  published  an  account  of  the  bacteriology  of 
swine  erysipelas;  this  was  the  beginning  of  an  active  period  with  dis- 
covery crowding  on  discovery.    In  1883  came  Koch's  announcement  of 


46  MEDICAL   BESEABCE   AND    EDUCATION 

the  comma  bacillus  as  the  cause  of  cholera;  in  1884  Loffler's  description 
of  the  bacillus  of  diphtheria  and  Nicolaier's  discovery  of  the  bacillus  of 
tetanus.  So  the  march  of  discovery  continued  until  the  roll  of  dis- 
eases of  known  etiology  in  a  short  time  included  typhoid  fever,  pneu- 
monia, meningitis,  influenza,  bubonic  plague  and  the  various  surgical 
suppurations. 

The  rapid  discoveries  of  disease-producing  microorganisms  estab- 
lished definitely  Pasteur's  doctrine  of  specificity  as  applied  to  etiology 
and  led  at  once  to  an  interest  in  public  health  measures  which  increased 
as  the  years  passed,  until  now  it  has  become  one  of  the  most  vital  inter- 
ests of  our  social  system.  Even  in  the  early  eighties,  with  a  knowledge  of 
the  etiology  and  mode  of  transmission  of  a  few  diseases  and  of  Lister's 
results  in  antiseptic  surgery,  it  was  possible  to  postulate  general  pro- 
phylactic measures  safeguarding  the  individual  and  the  community,  and 
as  knowledge  of  etiology  and  transmission  increased,  so  did  prophylaxis. 
Hygeia  was  again  enthroned  and  it  was  recognized  that  "  an  ounce  of 
prevention  is  worth  a  pound  of  cure." 

But  prophylaxis  was  not  entirely  satisfying.  If  a  specific  etiology, 
why  not  a  specific  therapy  for  bacterial  diseases  ?  Men  remembered  inoc- 
ulation for  smallpox  introduced  into  England  by  Lady  Mary  Wortley 
Montagu  early  in  the  eighteenth  century.  This  procedure,  the  inocu- 
lation of  healthy  individuals  with  material  from  the  pustules  of  those 
ill  with  a  mild  form  of  smallpox  had  materially  reduced  the  fatality  of 
the  disease.  The  procedure,  it  is  true,  had  been  made  illegal  in  Eng- 
land in  1840,  because  of  the  greater  success  and  less  danger  of  Jenner's 
wonderful  discovery  (1798)  of  vaccination  with  the  fluid  of  the  pustule 
of  cowpox.  Inoculation,  however,  despite  the  fact  that  it  sometimes 
caused  severe  and  fatal  cases  <)f  smallpox  and  perpetuated  foci  for  the 
dissemination  of  the  disease,  had  demonstrated  that  the  mild  inocula- 
tion disease  usually  protected  against  the  more  severe  forms.  That 
Jenner's  vaccine  was  a  transmitted  cowpox  did  not  militate  against  the 
general  theory  of  protecting  the  individual  against  a  severe  form  of  a 
disease  by  the  production  of  a  mild  form,  for  cowpox  was  generally 
considered  to  be  smallpox  modified  by  passage  through  another  host, 
the  bovine  animal.  If  such  results  could  be  obtained  against  a  disease, 
small-pox,  the  causal  agent  of  which  was  unknown,  how  much  easier 
to  vaccinate  against  a  disease  of  known  etiology ! 

This  was  therefore  the  first  line  of  attack  in  the  battle  for  a  spe- 


BESEAECB    IN   MEDICINE  47 

cific  therapy  of  the  infectious  diseases.  Already  Pasteur  was  at  work. 
An  epidemic  of  chicken-cholera,  in  1880,  offered  the  opportunity  for 
extended  experiments.  In  the  course  of  this  work,  a  chance  observa- 
tion gave  him  the  clue  to  vaccination  with  bacteria  of  attenuated  viru- 
lence. It  had  been  his  routine  practise  in  the  experimental  production 
of  chicken  cholera  to  use  fresh  24-hour  cultures ;  these  always  produced 
the  disease  readily.  But  in  the  course  of  the  work  it  happened  that  an 
old  culture  which  had  been  set  aside  for  a  few  weeks  and  forgotten, 
was  used,  with  the  unexpected  result  that  the  inoculated  hens,  although 
ill  for  a  while,  promptly  recovered,  and  what  was  more  surprising,  re- 
mained refractory  to  subsequent  inoculation  of  fresh  cultures,  though 
the  same  cultures  were  virulent  for  untreated  hens.  This  phenomenon, 
the  attenuation  of  virulence  due  to  artificial  cultivation,  Pasteur  used 
as  the  basis  of  a  treatment  by  vaccination,  which  had  the  immediate 
effect  (1880)  of  reducing  the  mortality  of  chicken  cholera  to  one  per 
cent,  and  the  more  remote  but  far  more  important  effect  of  stimu- 
lating the  study  of  specific  therapy.  Incidentally  it  was  the  link  be- 
tween Lady  Mary  Wortley  Montagu's  preventive  inoculation  and  Jen- 
ner's  vaccination,  on  the  one  hand,  and  modern  theories  of  the  produc- 
tion of  immunity  on  the  other. 

The  next  step  was  with  anthrax,  a  disease  of  cattle.  The  attenua- 
tion of  chicken  cholera  virus  had  been  due  to  artificial  cultivation,  but 
about  this  time  Toussaint,  of  the  veterinary  school  of  Toulouse,  made 
some  observations  on  the  attenuation  of  anthrax  bacilli  under  the  influ- 
ence of  increased  temperature  (heating  to  55°  C.  for  ten  minutes). 
His  observations,  however,  were  without  constant  results.  Pasteur,  who 
was  familiar  with  Toussaint's  work,  took  up  the  matter  and  after  a  thor- 
ough investigation  found  that  anthrax  bacilli  cultivated  at  a  temperature 
of  42°  to  43°  C,  became  attenuated,  and  this  attenuation  persisted  on 
artificial  cultivation  (1881).  The  inoculation  of  such  organisms  did 
not  cause  anthrax,  and  when  later  virulent  bacilli  of  anthrax  were  in- 
oculated, the  animals  were  found  to  be  immune.  This  was  the  scien- 
tific basis  of  the  celebrated  public  test  at  Melun.  Sixty  sheep  and  ten 
cows  were  placed  at  the  disposal  of  Pasteur;  twenty-five  of  the  sheep 
and  six  of  the  cows  were  to  be  vaccinated  with  attenuated  anthrax 
bacilli,  and  after  an  interval  of  twelve  to  fifteen  days  this  was  to  be 
repeated.  Later  this  lot,  and  also  twenty-five  untreated  sheep  and  four 
untreated  cows,  were  to  be  inoculated  with  a  virulent  culture  of  an- 


48  MEDICAL   BESEABCH   AND   EDUCATION 

thrax  bacilli.  Ten  sheep  were  to  have  no  treatment  at  all.  "The 
twenty-five  unvaccinated  sheep  will  all  perish,"  wrote  Pasteur,  "the 
twenty-five  vaccinated  ones  will  survive."  This  magnificent  faith  based 
on  exact  experimentation  was  justified.  All  happened  as  Pasteur  pre- 
dicted. For  medicine  a  new  era  was  at  hand;  Huxley,  in  1880,  esti- 
mated that  the  money  value  of  the  results  of  Pasteur's  vaccination 
treatment  was  sufficient  to  cover  the  war  indemnity  paid  by  France  to 
Germany  in  1879.  As  the  years  go  by  and  the  influence  of  Pasteur 
widens  the  horizon  of  preventive  medicine  and  the  treatment  of  disease 
by  immunizing  methods,  civilization's  indebtedness  to  Pasteur  is  almost 
beyond  the  grasp  of  the  imagination. 

His  discoveries  in  vaccination  against  swine  erysipelas  and  hydro- 
phobia are  as  fascinating,  in  their  "  mingling  of  experimental  skill  and 
scientific  imagination"  (Herter),  as  all  that  he  did  before.  But  while 
Pasteur  is  an  engaging  figure,  worthy  of  much  more  than  this  simple 
lecture  that  we  are  devoting  to  him,  yet  he  is  not  the  whole  story,  and  at 
this  point  we  must  turn  away  from  him  and  proceed  to  another  line  of 
advance:  one,  however,  which  was  in  part  the  result  of  his  genius  and 
his  indefatigable  labor.  This,  the  discovery  of  antitoxic  sera,  will  be 
discussed  in  the  next  lecture,  in  connection  with  other  modern  prob- 
lems and  methods  in  medical  research.  But  here  let  me  remind  you 
that  it  was  Pasteur,  afflicted  at  the  age  of  46  with  a  hemiplegic  paraly- 
sis— which,  by  the  way,  left  its  traces  during  the  remaining  twenty-five 
years  of  his  life — who  said. 

Work  can  be  made  into  a  pleasure,  and  alone  is  profitable  to  a  man,  to  his 
country,  to  the  world. 

It  would  be  difficult  to  find  in  any  field  of  human  endeavor  an  in- 
dividual whose  life  and  labors  exemplified  this  precept  better  than  do 
the  life  and  labors  of  Louis  Pasteur. 


LECTURE   IV 

Present-day  Methods  and  Problems 

The  important  activities  in  scientific  medicine  at  the  present  time 
may  be  said,  without  fear  of  contradiction,  to  be  in  the  departments 
of  (1)  immunology,^  (2)  protozoology,  (3)  chemotherapy,  (4)  physi- 

^  The  use  of  this  term  is  not  perhaps  above  criticism,  but  its  increasing  use 
and  need  of  some  comprehensive  word  to  cover  the  various  activities  represented 


BESEAECH   IN   MEDICINE  49 

ological  chemistry,  (5)  experimental  pharmacology  and  (6)  experi- 
mental pathology.  The  methods  and  problems  of  these  various  phases 
of  medicine  it  is  my  intention  to  discuss,  some  at  length,  others  briefly, 
in  the  present  lecture. 

Immunology  is  the  science  which  would  explain  and  apply  the 
mechanisms  by  means  of  which  the  animal  body  is  enabled  to  resist 
disease.  As  has  been  shown,  the  efforts  of  bacteriologists  until  about 
1890  were  devoted  almost  entirely  to  the  study  of  the  etiology  of  the 
infectious  diseases  and  to  attempts  to  combat  these  by  vaccination  with 
attenuated  viruses.  Another  phase  of  bacteriology  was,  however, 
already  under  way,  and  this,  in  the  earlier  nineties,  not  only  yielded 
results  of  great  practical  importance,  but  opened  a  new  and  ever-widen- 
ing field  of  investigation.  This  was  the  study  of  the  mode  of  action 
of  invading  bacteria  and  their  products,  that  is,  of  the  process  of  infec- 
tion and  intoxication,  and  the  mechanism  by  which  the  host  combats 
the  invasion  and  aborts  or  cures  such  infection  by  overwhelming  the 
foreign  organism.  One  of  the  first  results  was  the  study  of  a  group  of 
soluble  poisons,  toxins — formed  by  certain  bacteria  and  which  it  has 
been  found  are  responsible  not  only  for  the  symptoms  which  follow 
certain  infections,  but  also  for  that  effect  on  the  cells  of  the  host  which 
stimulates  the  formation  of  the  antibodies  which  we  call  antitoxins. 
Pasteur  in  his  study  of  chicken-cholera  had  noticed  that  a  bacteria-free 
filtrate  of  a  culture  of  the  specific  microorganism  of  this  disease  could 
cause  the  symptoms  produced  by  the  bacilli  themselves,  but  does  not 
seem  to  have  given  much  importance  to  the  observation.  Later  (1888) 
two  of  his  assistants,  Eoux  and  Yersin,  found  the  same  to  be  true  of 
filtered  cultures  of  the  diphtheria  bacillus.  Later  it  was  found  that  the 
tetanus  bacillus  and  the  bacillus  {B.  hotulismus)  of  meat  poisoning 
yielded  similar  soluble  poisons. 

Further  study  showed  that  the  various  bacterial  toxins  produce  not 
only  a  fatal  intoxication,  but  that  each  has  its  distinctive  effect,  as 
shown  by  symptoms  or  anatomical  lesion,  when  injected  into  animals, 
thus  demonstrating  that  the  poison  of  each  bacterium  possessed  a  spe- 
cific action.  This  led  not  only  to  a  better  understanding  of  the  pathol- 
ogy of  such  diseases  as  diphtheria  and  tetanus,  but  eventually,  and  of 
far  greater  importance,  to  the  discovery  of  curative  and  prophylactic 

by  tbe  term  ' '  studies  in  immunity ' '  and  ' '  serology, ' '  which  in  themselves  are  not 
adequate,  are  given  as  justification  of  its  use. 

5 


50  MEDICAL   EESEABCH   AND    EDUCATION 

sera,  or  as  they  are  generally  known,  antitoxic  sera.  The  first  step  in 
this  direction  was  taken  when  Behring  and  Kitasato  (1890)  showed 
that  animals  could  be  immunized  against  weakened  diphtheria  toxin 
and  that  the  serum  of  such  animals  is  capable  of  protecting  other 
animals  against  its  intoxication,  and,  moreover,  demonstrated  that  such 
a  serum  can  be  used  to  cure  the  toxic  symptoms  produced  by  the 
diphtheria  bacillus.  This  curative  power,  furthermore,  was  found  to 
be  due  not  to  an  action  on  the  bacteria,  but  to  a  neutralization  of  the 
toxin  which  the  bacteria  produced ;  also  the  serum  was  strictly  specific, 
that  is,  the  serum  of  an  animal  immunized  against  diphtheria  toxin 
protects  only  against  diphtheria;  that  prepared  by  the  use  of  tetanus 
bacilli,  only  against  tetanus.  This  led  directly  to  the  production  by 
Behring  and  Knorr  of  diphtheria  antitoxin  for  therapeutic  purposes 
(1894)  on  a  large  scale  and  to  a  general  awakening  as  to  the  possibili- 
ties of  serum  therapy.  The  great  benefits  of  diphtheria  antitoxin  as  a 
curative  and  prophylactic  serum  are  known  to  all ;  since  its  general  use, 
in  1896,  a  reduction  of  the  death  rate  in  diphtheria  from  45  per  cent. 
to  10  per  cent,  marks  this  therapeutic  measure  as  one  of  the  most  bril- 
liant discoveries  of  medicine  and  of  the  brilliant  century  in  which  this 
discovery  occurred. 

The  success  with  diphtheria  antitoxin  aroused  the  hope  that  a  gen- 
eral principle — that  of  the  formation  of  antibodies  for  the  toxins  of  all 
bacteria — had  been  established  on  the  basis  of  which  it  would  be  possible 
to  develop  curative  sera  for  all  infections.  This  expectation — on  ac- 
count of  the  simple  fact  that  most  bacteria  do  not  produce  soluble 
poisons — has  not  been  fulfilled ;  but  the  impetus  which  the  principle  of 
serumtherapy  gave  to  investigation  has  led  to  activity  of  great  and 
permanent  value,  and  to  the  development  of  a  new  science,  immunology 
or  serology,  as  it  is  variously  called,  which  attempts  to  establish  laws 
for  the  conditions  which  determine  natural  resistance  to  infectious  dis- 
eases and  the  factors  which  increase  or  diminish  this  resistance.  I 
approach  this  subject  with  hesitation,  for  the  many  difficulties  it  offers 
can  not  readily  be  overcome  in  a  short  presentation  such  as  this  must  be. 
A  few  brief  statements,  stripped  of  the  less  familiar  terms  may,  how- 
ever, serve  to  elucidate  the  main  lines  of  investigation. 

All  immunological  studies  are  based  on  the  known  fact  of  the  rein- 
forcement of  natural  resistance  to  disease,  as  illustrated  by  serum 
therapy  in  diphtheria  and  by  vaccine  therapy  in  anthrax.      The  at- 


BESEAECE    IN    MEDICINE 


51 


tempts  to  elucidate  the  principles  underlying  these  two  methods  have 
led  to  the  development  of  many  fruitful  hypotheses  and  theories,  and 
many  diagnostic  and  curative  procedures  of  great  value.  It  was  early 
evident  that  the  explanation  of  resistance  to  infection,  either  natural  or 
acquired,  must  be  sought  in  the  cells  or  fluids  of  the  body  and  especially 
of  the  blood.  Metchnikoff  (1884)  was  the  first  to  show  the  importance 
of  the  white  cells  of  the  blood  in  combating  infection  through  their 
power  of  engulfing  and  dissolving  bacteria,  and  his  pupils  have  supported 
his  views,  both  as  to  the  direct  and  indirect  influence  of  these  cells,  the 
leucocytes,  in  the  production  of  immunity.  On  the  other  hand,  since 
Nuttall,  in  1888,  demonstrated  the  bactericidal  power  of  the  fluids  of  the 
body,  and  particularly  of  the  blood  serum,  the  relation  of  the  body 
fluids  to  infection  and  immunity  has  been  incessantly  studied.  As  a 
result,  schools  have  arisen,  some  supporting  the  cellular  theory  and 
others  the  humoral  theory,  and  still  others  combining  both  theories  in 
the  attempt  to  reach  an  adequate  explanation  of  the  process  of  immu- 
nity. With  these  schools  are  associated  most  prominently  the  names  of 
Metchnikoff,  Ehrlich  and  Bordet. 

One  of  the  earliest  and  most  important  observations,  after  the  dis- 
covery of  antitoxins,  was  that  of  Pfeiffer  (1894).  This  was  the  demon- 
stration that  a  guinea-pig,  into  which  has  been  injected  the  spirillum  of 
cholera,  develops  in  its  body-fluids  a  substance  capable  of  dissolving  the 
cholera  spirillum.  This  bacteriolytic  substance  is  specific,  that  is,  it  de- 
stroys only  the  cholera  spirillum ;  and  Pf eiffer  and  his  followers,  push- 
ing their  investigations  further,  found  that  this  principle  of  a  specific 
lytic  body  could  be  applied  to  other  bacteria  and  to  foreign  animal  cells 
as  well.  Its  development  led  to  great  advances  in  the  theory  of  im- 
munity, to  the  development  of  the  fruitful  hypothesis  known  by  Ehr- 
lich's  name,  and  to  the  production  of  antibacterial  sera,  e.  g.,  anti- 
streptococcus  serum,  as  contrasted  with  antitoxic  sera. 

Likewise,  it  was  discovered  that  the  serum  of  animals  receiving  in- 
jections of  a  given  bacterium  had  the  power  to  agglutinate  this  organ- 
ism ;  and  moreover  that  this  principle  held  good  for  the  blood  serum  in 
certain  diseases  of  man.  Upon  these  observations  was  based  (1896) 
the  serum  (Widal)  reaction  for  typhoid  fever,  a  definitely  specific  and 
reliable  diagnostic  method  which  has  been  followed  by  many  other  val- 
uable tests  based  on  the  same  principle  and  grouped  under  the  general 
head  of  serum  diagnosis. 


52  MEDICAL   EESEABCH   AND   EDUCATION 

At  the  same  time  older  procedures  were  not  forgotten,  as  is  shown 
by  Haffkine's  extension  of  Pasteur's  principle  of  vaccination  to  include 
protective  vaccination  against  cholera  (1893)  and  plague  (1896)  and 
more  recently  Wright's  application  of  it  to  typhoid  fever.  Thus  the  last 
decade  of  the  nineteenth  century  is  marked  by  the  birth  of  both  serum- 
therapeutics  and  serum-diagnosis  and  by  the  extension  of  the  idea  of 
preventive  inoculation.  As  may  readily  be  seen,  the  fundamental  ob- 
servations of  Pasteur,  of  Behring  and  of  Pfeiffer  had  been  elaborated 
into  some  of  the  most  serviceable  principles,  acknowledged  at  the  mo- 
ment, in  the  science  and  practise  of  medicine.  Nor  is  this  influence  a 
matter  of  the  past.  In  our  own  day  has  been  established  the  theory  of 
specific  precipitation  of  foreign  proteins  (Uhlenhuth,  1901).  This  has 
led  to  the  elaboration  of  a  specific  test  for  the  differentiation  of  both 
vegetable  and  animal  proteins,  a  method  which  has  been  adopted  for 
the  determination  of  species,  not  only  in  bacteriology,  but  also  as  a 
medico-legal  test  for  determining  the  origin  of  blood  stains  and  as  a 
general  biological  procedure. 

So  also,  through  the  work  of  Denys  and  later  of  A.  E.  Wright,  fi 
body  has  been  recognized  in  the  serum  which  had  the  power  to  prepare 
bacteria  for  ingestion  and  digestion  by  the  leucoc3rte.  To  this  body  the 
name  of  opsonin  or  tropin  has  been  given.  You  will  remember  that 
MetchnikofE  discovered  the  fact  that  the  white  cells  of  the  blood  have 
the  power  to  engulf  bacteria,  Wright  supplemented  this  conception  of 
demonstrating  that  a  substance  in  the  serum  could  so  affect  bacteria 
that  they  would  be  taken  up  more  readily  and  in  greater  numbers ;  also 
he  demonstrated  that  this  opsonic  power  of  the  serum  could  be  in- 
creased, and  as  the  results  of  his  teachings  a  definite  opsonic  therapy 
has  developed.  This  treatment  depends  on  the  principle  of  vaccination 
with  bacterial  products.  Before  Wright,  with  the  exception  of  Pas- 
teur's treatment  for  hydrophobia,  vaccination  was  used  as  a  preventive 
measure  only,  but  the  studies  which  his  observations  have  stimulated 
have  led  to  very  satisfactory  results  in  the  treatment  of  certain  local 
infections  as  those  due  to  the  pus  cocci  and  colon  bacillus.  Also, 
these  studies  have  extended  the  practise  of  immunizing  vaccination,  as 
a  prophylactic  measure  with,  it  has  been  claimed,  most  favorable  re- 
sults in  the  prevention  of  typhoid  fever.  Por  example  the  sanitary 
record  of  the  maneuver  division  of  the  United  States  Army  recently 
stationed  on  the  Mexican  border  shows  that  in  a  body  of  8,097  enlisted 


SESEAECH    IN   MEDICINE  63 

men,  careful  sanitation  and  antityphoid  inoculation  prevented  almost 
entirely  the  occurrence  of  typhoid  fever;  only  one  case  of  typhoid  fever 
was  observed,  and  it  was  not  fatal ;  while  at  the  same  time  in  the  near-by 
city  of  San  Antonio  49  cases  were  reported.  Comparing  the  record  of  ■ 
the  maneuver  division  with  that  of  a  division  of  the  Seventh  Army 
Corps  stationed  at  Jacksonville,  under  quite  similar  circumstances  in 
1898,  we  have  one  case  of  typhoid  among  the  8,097  men  of  the  former 
and  2,693  undoubted  cases  among  the  10,759  men  of  the  latter  division. 
It  must  be  admitted  in  regard  to  this  record  of  the  maneuver  division, 
that  it  is  difiScult  to  say  to  what  extent  the  excellent  showing  was  due 
to  careful  sanitation  and  to  what  extent  to  the  antityphoid  inoculation, 
but  past  experience  with  troops  in  camp  would  indicate  that  inocula- 
tion was  an  important  factor  at  San  Antonio.  The  question  of  the 
value  of  preventive  inoculation  is,  however,  still  an  open  one.  So  also 
are  other  applications  of  the  principles  of  immunity,  as  the  production 
of  anti-sera  for  snake- venom,  and  for  the  irritant  (and  perhaps  intoxi- 
cating) vegetable  agent  causing  hay  fever. 

I  have  earlier  in  this  lecture  referred  to  methods  of  serum  diagnosis 
depending  on  agglutination  or  solution  of  bacteria  or  on  the  precipita- 
tion of  protein.  Immunology  has  recently  contributed  to  medicine 
another  diagnostic  method  of  great  value.  Its  principle  is  that  of  com- 
plement fixation,  the  theory  of  which  is  too  complicated  for  brief  ex- 
planation, but  the  method  as  applied  to  syphilis,  in  the  well-known 
Wassermann  test,  has  since  1906  occupied  a  most  prominent  position  in 
the  diagnosis  and  treatment  of  this  disease,  and  is  now  accepted  as  a 
method  of  great  value  in  the  more  obscure  cases,  and  numerous  attempts 
are  being  made  to  apply  the  principle  to  other  diseases. 

Another  phase  of  immunological  study  is  that  of  anaphylaxis,  a  sub- 
ject concerning  which  the  professor  of  pathology  in  this  university  is 
one  of  the  best  known  authorities.  Anaphylaxis,  the  condition  of  increased 
susceptibility  dependent  on  the  sensitization  of  an  organism  to  a  foreign 
protein,  is  by  no  means  thoroughly  understood,  but  it  has  thrown  light 
upon  immunity  from  a  new  angle  and  has  stimulated  an  enormous 
amount  of  investigation.  Its  utilization  in  the  detection  of  specific  pro- 
teins, its  apparent  explanation  of  the  tuberculin,  mallein  and  similar 
reactions,  the  light  it  has  thrown  on  serum  sickness,  so-called,  and  the 
possibility  it  offers  of  explaining  diseases  characterized  by  critical 
phases,  have  attracted  a  host  of  investigators,  who  see  in  it  the  key  to 


54  MEDICAL   EESEABCE   AND    EDUCATION 

many  little  understood  phenomena  of  disease.  As  yet  the  practical  re- 
sults are  meager,  but  the  ultimate  outcome  promises  much  for  medicine. 

Another  field,  and  one  in  which  American  investigations  have  been 
of  the  greatest  importance,  is  the  study  of  diseases  the  etiology  of  which 
is  unknown,  but  which,  it  has  been  supposed,  are  in  some  instances  due 
to  filtrable  or  ultramicroscopic  viruses.  The  recent  work  on  poliomye- 
litis by  Flexner  and  his  associates  is  an  example.  This  disease,  appear- 
ing irregularly  in  sporadic  and  epidemic  form,  was  in  the  past  not  defi- 
nitely grouped  among  the  infectious  diseases.  All  attempts  to  find  a 
causative  microorganism  have  failed.  The  workers  of  the  Eockefeller 
Institute  and  also  certain  European  investigators  have  shown  that  the 
tissues  of  the  central  nervous  system  contain  the  virus,  and  that  when 
the  fluids  of  such  tissues  are  injected  into  monkeys,  typical  poliomyelitis 
results.  Moreover,  the  experimental  evidence  points  to  an  elimination 
of  the  virus  through  the  upper  respiratory  passages,  thus  offering  a  sub- 
stantial basis  for  scientific  prophylaxis  through  the  proper  care  of  the 
secretions  of  the  nose  and  throat.  Such  investigations  show  how  im- 
portant the  methods  of  immunology  are,  for  here  we  have  a  disease 
which,  as  the  result  of  the  application  of  such  methods,  is  definitely 
23laced  among  the  transmissible  diseases  and  is  given  a  satisfactory 
theory  for  prophylaxis  in  spite  of  an  utter  absence  of  knowledge  con- 
■cerning  its  causal  agent.  An  analogy  is  seen  in  yellow  fever,  the  micro- 
organism causing  which  we  do  not  know  and  for  which  we  have  no 
specific  treatment,  but  which  is  controlled  simply  through  our  knowl- 
edge of  its  transmission  by  the  mosquito. 

While  on  the  subject  of  Flexner  and  his  work  mention  must  be  made 
of  the  most  important  contribution  in  recent  years  to  our  list  of  curative 
sera,  the  antimeningococcus  serum.  The  production  of  this  serum, 
which  in  the  best  form  is  the  result  of  the  labors  of  Flexner  and  his  as- 
sociates, is  an  accomplishment  which,  in  reducing  enormously  the  mor- 
tality of  epidemic  meningitis,  is  in  itself  a  sufficient  justification  for  the 
establishment  of  the  Eockefeller  Institute.  The  beneficial  results  of  its 
use  are  very  definite  and  the  mode  of  its  administration,  by  direct  in- 
jection into  the  spinal  canal,  has  been  of  great  value  in  emphasizing  the 
importance  of  the  local  treatment  of  localized  infections. 

Many  other  phases  of  activity  in  the  field  of  immunity  might  be 
presented,  but  this  brief  and  disconnected  summary  will,  I  hope,  suflBce 
to  indicate  something  of  actual  accomplishment  in  this  field,  the  main 


BESEAECH    IX    MEDICINE  55 

lines  of  present  endeavor,  and  the  many  opportunities  for  future 
achievement.  Much  of  present-day  effort  may  not  lead  immediately  to 
tangible  results — an  outcome  not  uncommon  in  medical  research — but 
the  volume  of  work  in  progress  and  the  vigor  with  which  it  is  being 
prosecuted  promises  ultimately  the  solution  of  the  many  problems  of 
the  infectious  diseases. 

The  Investigation  of  Cancer. — In  no  field  of  medical  science  has  the 
modern  experimental  method  given  greater  results  in  a  few  brief  years 
and  offered  greater  promise  for  the  future  than  in  the  study  of  that 
fatal  and  obscure  disease,  cancer.  Owing  to  the  brilliant  initiative  of 
Jensen  in  Denmark  and  Leo  Loeb  in  this  country,  it  has  been  shown 
that  a  form  of  cancer  occurs  in  certain  lower  animals,  particularly  in 
rats  and  mice,  that  can  be  artificially  transmitted  from  one  animal  to 
another  of  the  same  species.  This  fact  has  afforded  a  means  of  study- 
ing in  detail  the  method  by  which  a  malignant  tumor  grows  in  the 
body  and  more  particularly  has  thrown  light  on  the  resistance  or  im- 
munity to  tumor  growth  which  may  occur  naturally  in  certain  individ- 
uals and  which  may  even  be  artificially  produced.  Scattered  over  the 
world  are  small  groups  of  individuals,  more  particularly  in  England, 
in  Germany  and  in  America,  who  are  devoting  their  entire  energies  to 
the  solution  of  this  problem.  From  several  divergent  sources  have  come 
published  results  of  experiments  which  offer  the  greatest  promise  that 
we  may  soon  learn  a  method  of  curing  these  tumors.  Already  Ehrlich 
and  Wassermann  have  shown  the  possibility  of  preparing  specific  cellular 
poisons  for  cancer  analogous  to  those  used  in  curing  protozoan  diseases. 
The  final  clue  which  will  unravel  the  mystery  of  this  complex  disease 
would  not  appear  to  be  as  yet  fully  in  hand,  and  yet  I  think  no  one  of 
those  most  conversant  with  the  problem  would  be  surprised  to  find 
to-morrow  that  it  has  been  discovered  and  that  cancer  was  curable. 

Protozoology. — It  is  of  interest  that  about  the  year  1890,  when  bac- 
teriologists ceased  to  announce  discoveries  with  their  accustomed  regu- 
larity, owing  to  the  fact  that  all  readily  recognized  pathologenic  bac- 
teria had  been  discovered,  the  systematic  study  of  protozoa  began  and 
some  of  the  single-cell  forms  of  life  in  the  animal  kingdom  soon  took  a 
place  as  disease-producers  alongside  the  corresponding  form  of  the  vege- 
table kingdom.  Until  this  time,  protozoa  had  been  found  in  only  two 
diseases  of  man,  dysentery  and  malaria.  In  the  year  1890  appeared  the 
first  books  on  the  subject  of  protozoa  as  causes  of  disease,  a  small  vol- 


66  MEDICAL   BESEABCH   AND   EDUCATION 

ume  of  one  hundred  pages  by  L.  Pfeifier,  followed  in  the  next  year  by 
Doflein's  more  extensive  discussion  of  the  same  subject  from  the 
broader  biological  point  of  view.  The  bacteriologists  of  the  preceding 
decade  had  by  their  efforts  limited  the  number  of  diseases  in  which  a 
bacterial  etiology  could  be  readily  shown  and  it  was  natural,  therefore, 
that  the  attention  of  investigators  turned  to  the  study  of  other  micro- 
organisms as  factors  in  the  production  of  disease.  The  careful  tech- 
nic  of  the  bacteriologist  had  shown  the  methods  to  be  used  in  the 
study  of  etiology,  and,  undoubtedly,  the  publications  of  Pfeiffer  and 
Doflein  stimulated  general  interest  in  the  search  for  pathogenic  pro- 
tozoa. However  this  may  be,  it  is  a  matter  of  record  that  in  1890 
"  only  two  human  diseases  were  suspected  of  being  caused  by  protozoa. 
.  .  .  To-day  more  than  fifteen  are  known  or  suspected  to  be  of  pro- 
tozoan origin"  (Calkins). 

In  the  discussion  of  bacteriology  I  have  referred  to  Leeuwenhoek  as 
the  first  to  see  bacteria;  he  was  likewise  the  first  to  see  protozoa  (1675). 
Two  hundred  years  later,  Biitschli  (1875)  offered  conclusive  evidence 
of  the  unicellular  nature  of  these  minute  forms  of  animal  life.  In  the 
intervening  period,  however,  owing  largely  to  the  work  of  0.  F.  Muller 
(1786),  Ehrenberg  (1833-38)  and  Dujardin  (1835-41),  many  forms 
had  been  removed  from  the  "  chaos  animalculae,"  the  name  under  which 
Cuvier  had  classified  them  and  their  structure  had  been  studied  by 
Siebold  (1845)  and  Max  Schultze  (1863).  In  this  later  period  also 
several  forms  now  familiar  to  us  as  occasional  parasites  of  man  had 
been  described;  as  the  TricJiomonas  vaginalis  (Donne  in  1837),  the 
Cercomonas  Jiominis  (Davaine,  1857),  the  Balantidium  coli  (Malm- 
sten,  1857)  and  the  Lamblia  intestinalis  (Lambl,  1859). 

The  first  parasitic  protozoon,  however,  to  be  definitely  associated 
with  a  specific  disease  of  man  was  the  ameba  discovered  by  Lambl 
(1860),  first  observed  in  the  human  intestine  by  Losch  in  1875,  and 
said  by  the  latter  to  be  the  cause  of  amebic  dysentery.  In  1891  Coun- 
cilman and  Lafleur,  after  a  very  accurate  study  of  this  disease,  as  it 
occurred  in  Baltimore,  came  to  the  conclusion  that  two  types  of  amebae 
must  be  recognized ;  one,  the  Ameia  coli,  was  harmless,  another,  which 
they  called  Ameba  dysenteries,  they  claimed  to  be  the  cause  of  tropical 
dysentery.  In  this  view  they  were  supported  later  by  the  feeding 
experiments  of  Casagrandi  and  Barbagallo  (1897)  and  of  Schaudinn 
(1903)  ;  the  latter  also  introduced  the  name  Entameha  histolytica  for 


BESEABCH    IN   MEDICINE  57 

the  pathogenic  form,  and  Eiitameha  coli  for  the  harmless  form.  It  has 
since  been  found  that  two  forms  of  tropical  dysentery  exist,  one  of 
which,  as  shown  by  Shiga,  Kruse  and  Flexner,  is  due  to  bacteria — ^but 
equally  definitely  has  the  etiology  of  an  amebic  form  been  established. 
In  the  meantime  another  protozoan  disease  was  being  investigated. 
Laveran,  a  French  military  physician,  stationed  in  Algiers,  announced 
in  1880  that  the  dancing  pigmented  bodies  frequently  seen  in  the  red 
blood  cells  in  malaria  were  altered  hemoglobin  granules  within  a  pro- 
tozoon  to  which  he  gave  the  name  Oscillaria  malarice.  This  name  was 
altered  by  Marchiafava  and  Celli  to  Plasmodium  malarice,  in  1885,  and 
Golgi,  in  1886,  by  demonstrating  that  the  characteristic  paroxysms  of 
the  disease  coincide  with  the  segmentation  or  sporulation  of  this  para- 
site, settled  definitely  the  question  of  its  etiologic  relation  to  malaria. 
The  work  on  malaria  constituted  a  very  large  part  of  the  activity  in 
medical  investigation  at  this  time.  Until  the  middle  of  the  nineties, 
many  investigators  were  interesting  themselves  in  the  study  of  the  dif- 
ferent forms  of  parasites  concerned,  their  life  history  and  the  methods 
for  demonstrating  them ;  these  activities,  with  the  study  of  similar  para- 
sites in  birds,  gave  a  great  impetus  to  the  study  of  pathogenic  protozoa, 
and  prepared  many  workers  for  a  wider  field. 

Nevertheless,  but  few  were  prepared  for  the  wonderful  announce- 
ment by  Smith  and  Kilbourne,  in  1893,  of  the  transmission  of  a  proto- 
zoan disease  through  a  blood-sucking  insect.  In  this,  the  work  of  our 
own  countrymen,  on  a  malaria-like  disease  of  cattle,  Texas  fever,  the 
tick  was  shown  to  be  the  carrier  of  the  Pirosplasma  higeminum,  the 
organism  responsible  for  the  disease.  The  importance  of  this  observa- 
tion can  not  be  over-estimated.  It  was  the  finger-post  indicating  the 
way  to  progress  in  the  study  of  the  transmission,  and  therefore  of  the 
prevention,  of  protozoan  disease,  and  to  Smith  and  Kilbourne  belongs 
the  credit  of  this  great  advance,  which,  it  must  be  admitted,  had  a  great 
influence  on  the  study  of  the  transmission  of  malaria  and  yellow  fever. 
Many  suggestions  had  been  made  from  time  to  time  that  these  diseases 
might  be  due  to  transmission  by  the  mosquito;  and  these  theories  be- 
came indisputable  fact  when  Eoss  announced  from  India  in  1897-99 
that  the  malaria  of  birds  was  transmitted  by  a  species  of  mosquito 
(Culex)  and  when  Grassi,  Bignami  and  Bastianelli  (1898-99)  likewise 
demonstrated  that  malaria  of  man  is  transmitted  by  another  species  of 
mosquito  {Anopheles).     But  before  this,  Bruce's  study  (1894^97)  of 


58  MEDICAL    BESEAECH   AND    EDUCATION 

the  South  African  disease  of  cattle,  which  you  may  remember  Living- 
ston refers  to  as  the  "  tse-tse  fly  disease/'  resulted  in  the  discovery  of 
the  protozoan  origin  of  the  disease  and  the  imjDortance  of  the  tse-tse  fly 
(Glossina  morsitans)  in  its  transmission. 

Soon  followed  (1900-01)  the  discovery  by  the  United  States  Army 
Yellow  Fever  Commission — Reed,  Carroll,  Agramonte  and  Lazear — of 
the  transmission  of  yellow  fever  by  a  third  species  of  mosquito,  the 
Stegomyia,  and  in  1903  Bruce  announced  that  the  sleeping  sickness  of 
Africa,  due  to  a  trypanosome,  is  transmitted  by  the  tse-tse  fly  {Glossina 
palpalis) .  So  also  certain  closely  allied  diseases  of  the  far  east,  known 
as  dum-dum  fever,  kala-azar,  oriental  sore,  etc.,  were  shown  to  be  due 
to  protozoa  and  to  be  probably  transmitted  by  an  insect. 

The  importance  of  these  discoveries  for  prophylaxis  was  far  reach- 
ing. It  had  long  been  known  that  malaria  could  be  cured  by  quinine, 
but  physicians  in  face  of  constant  infections  and  reinfections  were 
helpless.  Now,  the  knowledge  that  the  disease  is  transmitted  by  a  mos- 
quito, and  by  but  one  genus  of  mosquito,  the  Anopheles,  allows  the 
health  officer  to  step  in  and  by  draining  the  breeding  places  of  the  mos- 
quito to  destroy  the  agent  of  transmission  or,  if  this  is  impossible,  to 
prevent  contact  with  the  mosquito  by  screens  and  other  mechanical 
means.  As  far  as  we  know,  the  parasite  of  malaria  exists  only  in 
infected  man  and  in  infected  mosquito.  Perpetuation  of  the  disease  is 
due  to  the  perpetuation  of  the  cycle,  man  to  mosquito,  mosquito  to  man. 
If  the  parasite  is  destroyed  in  man  or  the  Anopheles  is  not  allowed  to 
breed,  the  disease  disappears.  Not  only  has  this  been  demonstrated 
experimentally,  but  it  is  in  many  communities  a  commonplace  of 
sanitation. 

Yellow  fever  is  a  disease,  the  causal  agent  of  which  is  unknown, 
but  so  carefully  has  its  prophylaxis  been  worked  out  on  the  basis  of  its 
transmission  by  the  mosquito,  as  a  result  of  the  work  of  Eead,  Carroll, 
Lazear  and  Agramonte,  that  an  epidemic  of  yellow  fever  would  now  be 
considered  as  due  to  ignorance  or  criminal  carelessness  on  the  part  of 
those  responsible  for  the  public  health.  It  is  unnecessary  for  me  to 
remind  this  audience  of  the  heroism  of  Lazear  and  his  associates  and 
of  the  non-immune  enlisted  American  soldiers,  who  offered  themselves 
for  experimental  inoculation  through  the  bite  of  mosquitoes  infected 
with  yellow  fever.  To  their  labors  we,  as  a  people,  owe  the  present 
magnificent  progress  in  the  Canal  Zone,  the  absence  of  yellow  fever  in 


BE  SEARCH    IN    MEDICINE  59 

the  Gulf  ports,  an  increase  in  human  comfort  and  happiness  and  an 
increase  in  national  prosperity  and  national  progress ;  but  still  more,  to 
them,  as  also  to  Eicketts,  who  investigated  Mexican  typhus  and  suc- 
cumbed to  it,  and  to  Walter  Myers  and  Everett  Button,  of  the  Liverpool 
School,  our  science  owes  much  in  methods  and  in  ideals. 

Truly,  no  field  of  medicine  offers  so  much  of  tragedy,  of  romance 
and  of  spectacular  discovery  as  that  of  the  pathogenic  protozoa,  and 
few  offer  such  great  difficulties.  It  is,  however,  one  of  the  most 
promising  fields  of  present-day  effort  and  one  which  I  would  like  to 
present  more  in  detail.  It  must,  however,  suffice  to  end  this  presen- 
tation with  mere  mention  of  the  successful  cultivation  of  amebs 
(Mesnil  and  Mouton),  the  cultivation  of  the  trypanosomes  (Novy  and 
MacISTeal),  the  discovery  by  Schaudinn  and  Hoffman  of  the  spirochete, 
which  we  now  know  to  be  the  cause  of  syphilis,  and  the  finding  of  a 
very  similar  organism  in  yaws.  Time  might  also  be  given  to  the 
various  trypanosomes,  to  the  spirochetes  causing  diseases  of  cattle 
and  poultry  and  to  the  Negri  bodies  of  rabies;  also  the  discussion 
might  be  extended  to  include  the  broader  field  of  tropical  medicine, 
but  instead,  as  it  is  the  direct  outcome  of  the  study  of  protozoa,  I 
must  turn  to  a  new  phase  of  research  in  medicine,  that  known  as 
chemotherapy. 

Chemotherapy 

As  the  study  of  protozoan  diseases  progressed  it  soon  became  evi- 
dent that  the  method  of  combating  such  diseases  must  be  different  from 
that  used  against  diseases  due  to  bacteria.  The  chronicity  of  amebic 
dysentery  and  relapses  in  malaria  indicated  that  the  protozoan  diseases 
are  not  self-limited  and  therefore  not  characterized  by  the  development 
of  immune  bodies,  similar  to  those  of  the  acute  bacterial  diseases;  also 
artificial  cultivation  failed  to  demonstrate  that  protozoa  yielded  bodies 
analogous  to  bacterial  toxins,  capable  of  producing,  on  injection,  bodies 
with  efficient  antitoxic  power.  These  and  other  facts  precluded,  there- 
fore, a  therapy  based  on  the  principles  applied  to  bacterial  vaccines  or 
antitoxins. 

The  beneficial  effect  of  quinine  in  the  treatment  of  malaria  and  the 
cellucidal  action  of  quinine  on  the  ameba  and  other  protozoan  forms 
indicated  that  a  therapy,  to  be  successful,  must  be  one  in  which  a  sub- 
stance toxic  for  the  protozoa  in  question  is  brought  into  direct  contact 
with  it.     The  establishment  of  such  therapy  and  incidentally  the  crea- 


60  MEDICAL   BESEABCH   AND    EDUCATION 

tion  of  a  new  science,  that  of  specific  chemical  therapeutics,  has 
been  the  work,  in  the  past  seven  years  of  Professor  Ehrlich,  of  the 
Eoyal  Prussian  Institution  for  Experimental  Therapeutics  at  Frank- 
furt. This  new  therapy  is  based  on  the  principle  that  "  a  specific 
chemical  aflfinity  exists  between  specific  living  cells  and  specific  chem- 
ical substances."  This  principle  has  always  been  the  main  theme  of 
Ehrlich's  work,  as  is  seen  in  his  application  of  the  aniline  dyes  to  the 
study  of  the  cells  of  the  blood,  his  studies  on  vital  staining  and  the 
selective  action  of  methylene  blue  on  the  nervous  system,  the  use  of 
methylene  blue  in  the  study  of  the  oxidations  and  reductions  occurring 
in  tissues,  and  his  extensive  studies  in  immunity.  This  experience, 
covering  a  period  of  twenty-five  years,  led  Ehrlich  to  the  belief  that 
"  for  each  specific  parasite  a  specific  curative  drug  must  and  could  be 
found."     And  upon  this  assumption  he  began  his  experiments. 

To  appreciate  thoroughly  the  difficulties  of  this  task  and  the  magni- 
tude of  the  results,  it  must  be  understood  that  Ehrlich  proposed  a 
sterilization  of  the  body  in  so  far  as  the  microorganism,  against  which 
the  specific  remedy  was  aimed,  was  concerned.  The  destruction  of 
bacteria  or  protozoa  outside  the  body  by  chemical  means  is  a  common- 
place of  surgical  and  public  health  measures;  but  the  destruction  of 
living  microorganisms  within  the  living  body  had  never,  until  Ehrlich 
accomplished  it,  been  possible  without,  at  the  same  time,  destroying 
also,  in  part  or  in  toto,  the  cells  of  the  host.  To  avoid  the  latter  it 
was  necessary,  therefore,  that  the  protozoa-destroying  substance  should 
have  a  specific  chemical  affinity  for  the  protozoa  in  question,  but  little 
or  no  chemical  affinity  for  the  cells  of  the  host. 

It  is  impossible  to  give  the  details  of  Ehrlich's  seven  years  of  work 
on  this  problem;  a  brief  description  of  the  main  results  must  suffice. 
The  first  work  was  done  with  trypanosomes,  the  mouse,  which  could  be 
readily  infected,  being  used  as  an  experimental  animal.  After  testing, 
with  the  aid  of  his  assistant,  K.  Shiga,  many  hundreds  of  dye-stuffs, 
some  old  and  some  new,  one,  a  member  of  the  benzidin  group,  was 
found  which  retarded  the  progress  of  the  trypanosome  infection  for 
several  days.  This  led  to  a  limitation  of  the  experimentation  to  a 
study  of  the  synthetic  products  of  the  benzidin  group,  many  of  which 
were  made  for  the  first  time  by  Ehrlich  and  his  assistants.  The  result 
was  the  discovery  of  a  substance  which  exerted  an  actual  curative  effect 
upon  trypanosomiasis.     This  substance,  a  red  dye  destroying  trypano- 


BESEABCH    IN   MEDICINE  61 

somes,  was  given  the  name  trypan  red  (trypan  roth).  If  twenty-four 
hours  after  mice  had  been  infected  with  the  trypanosome  of  Mai  de 
Caderas,  a  single  injection  of  this  dye  was  made,  animals  which  ordi- 
narily died  in  four  to  five  days  went  on  to  permanent  recovery.  The 
blood,  twenty-four  hours  after  injection,  was  found  to  be  free  of  try- 
panosomes,  which  indicated  that  the  effect  of  the  injection  was  to 
destroy  absolutely  every  infecting  protozoan.  Thus  was  demonstrated 
for  the  first  time  the  possibility  of  completely  sterilizing  the  animal  body 
by  a  chemical  disinfectant  without  injury  to  the  cells  of  the  host. 

In  the  course  of  this  work  an  interesting  observation  was  made. 
If,  instead  of  a  dose  necessary  to  destroy  all  the  trypanosomes,  a 
slightly  smaller  dose  was  injected,  the  trypanosomes  would  disappear 
from  the  circulation  for  a  short  time  and  later  reappear.  If  such 
injection  was  repeated  at  intervals,  the  period  of  disappearance  of  the 
trypanosome  would  gradually  shorten  until  finally  the  drug  would  have 
no  effect  on  the  infecting  organism ;  in  other  words,  a  strain  of  trypano- 
somes had  been  developed  which  were  resistant,  immunized  as  it  were, 
to  trypan  red  and  this  resistance  could  be  transmitted  through  many 
generations.  Also,  it  was  found  that  trypan  red  was  a  curative  agent 
only  for  the  infection  in  mice;  on  the  trypanosome  diseases  of  larger 
animals,  as  horses  and  cattle,  it  had  no  curative  effect.  However,  the 
experience  with  trypan-red  pointed  the  way  to  a  solution  of  the  diflB- 
culty;  either  a  drug  must  be  found  which  by  a  single  injection  would 
kill  every  parasite,  or  several  different  drugs  must  be  used,  which,  act- 
ing on  the  same  parasite,  and  thus  allowing  a  combination  treatment, 
would  lead  to  a  cure  without  the  danger,  to  the  host,  of  a  single  massive 
dose.  It  is  impossible  in  the  scope  of  these  lectures  to  follow  in  detail 
Ehrlich's  work  or  to  go  into  the  complicated  chemistry  of  the  substances 
used.  It  must  suffice  to  say  that  as  the  work  went  on,  Ehrlich  and 
Weinberg  found  a  substitution  produced  of  trypan-red,  amidotrypan-red, 
which  destroyed  the  virulent  parasite  of  nagana,  the  tse-tse  fly  disease, 
and  that  Mesnil  and  Nicolle,  using  the  blue  and  violet  azo-dyestuffs, 
prepared  a  trypan  blue  and  trypan  violet  which  caused  the  disappear- 
ance of  the  parasites  of  nagana,  surra  and  mal  de  Caderas. 

Another  line  of  progress  was  through  various  combinations  of  anilin 
with  arsenic.  Before  Ehrlich  entered  this  field,  Bruce  had  found 
arsenic  to  be  a  drug  of  value  in  treating  the  trypanosomiasis  of  horses 
(surra)  and  Thomas  had  found  that  atoxyl,  a  combination  of  arsenic 


62  MEDICAL   EESEABCE   AND    EDUCATION 

and  anilin,  would  cure  a  large  percentage  of  infected  animals.  This 
latter  substance  had  also  been  used  in  the  treatment  of  the  human 
disease,  sleeping  sickness.  Ehrlich  made  a  thorough  study  of  arsenic 
compounds,  and  the  result  was  the  combination,  arsenophenylglycin,  a 
single  dose  of  which  absolutely  and  permanently  cures  all  animals  suf- 
fering from  trypanosome  infection. 

At  about  this  stage  of  the  development  of  chemotherapy,  Uhlen- 
huth  and  Salmon  published  an  account  of  the  brilliant  use  of  atoxyl  in 
the  treatment  of  syphilis,  which  as  we  have  mentioned,  is  due  to  a 
protozoan,  the  spirocheta  pallida.  Unfortunately,  as  atoxyl  sometimes 
caused  blindness,  its  use  was  not  without  danger  and  therefore  not  de- 
sirable. So  Ehrlich  immediately  turned  his  attention  to  the  protozoan 
diseases  caused  by  spirilla,  as  chicken  spirillosis,  relapsing  fever  and 
syphilis.  His  labors  on  these  diseases  constitute  one  of  the  most  fas- 
cinating of  modern  laboratory  studies  and  his  results  are  among  the 
greatest  of  scientific  discoveries.  His  intimate  knowledge  of  the  con- 
stitution of  atoxyl  and  other  arsenic  preparations  allowed  him  to  pro- 
ceed rapidly  with  "  a  great  variety  of  substitutions,  and  innumerable 
arsenic  derivatives  were  synthetized."  As  human  syphilis  could  be 
transmitted  to  the  rabbit  and  relapsing  fever  to  the  mouse,  the  power 
of  these  preparations,  as  soon  as  manufactured,  could  be  tested  in  the 
laboratory.  The  object,  of  course,  was  to  find  a  substance  which  would 
kill  the  spirochetes  without  injury  to  the  host.  The  result  was  the 
justly  celebrated  Ehrlich-Hata  606,  chemically  known  as  dioxydiamido- 
arsenobenzol,  sometimes  shortened  to  arsenobenzol,  and,  more  recently, 
receiving  the  commercial  name,  Salvarsan.  This  substance  in  a  single 
dose,  58  times  smaller  than  the  dosis  tolerata  (the  largest  dose  which 
could  be  given  with  safety),  cured  definitely  chicken  spirillosis;  a  single 
small  dose  destroyed  the  spirolla  of  relapsing  fever  in  infected  mice, 
and  a  single  injection  of  one  seventh  the  dosis  tolerata,  caused  the 
spirochete  of  syphilis  to  disappear  completely  from  the  experimental 
lesions  of  the  rabbit  within  twenty-four  hours.  This  last  experience 
naturally  aroused  the  hope  of  curing  syphilis  in  man  by  a  single  injec- 
tion given  in  the  early  stages.  Such  treatment,  if  successful,  would 
supersede,  or  at  least  supplement,  the  empirical  treatment  by  mercury 
which  required  a  course  of  several  years'  treatment  before  a  cure  could 
be  assured.  The  toxicity  of  the  substance  was,  therefore,  tested  on  dogs 
and  then,  to  make  sure  it  had  no  ill  effects,  on  healthy  men  (assistants 


BESEABCH    IX    MEDICINE  63 

of  Professor  Alt),  who  volunteered  for  the  purpose  and  finally  the 
therapeutic  effect  was  tried  on  relapsing  fever  in  man.  Iversen,  of 
Russia,  to  whom  this  work  was  entrusted,  found  that  one  injection  com- 
pletely cured  relapsing  fever  in  90  per  cent,  of  his  patients.  Finally 
the  substance  was  used  in  the  treatment  of  syphilis  in  man.  The  com- 
pleteness and  rapidity  of  the  curative  action  have  been  astounding. 
The  effect  on  the  lesions  of  the  primary  and  secondary  stages  is  to  cause 
them  to  heal  or  disappear  promptly;  the  spirochetes  can  not  be  found 
after  a  few  days  and  the  effect  is  apparently  one  of  complete  steriliza- 
tion. Thousands  of  reports  in  the  medical  press  confirm  the  general 
beneficial  effect  of  this  remedy  and  testify  to  the  absence  of  ill-effects 
when  properly  administered.  Even  though  further  experience  may 
modify  the  present  optimism,  nothing  can  detract  from  the  magnificent 
service  by  which  Ehrlich  and  his  pupils  have  benefited  humanity  and 
added  to  the  glory  of  medical  science  by  establishing  the  principle  of 
specific  chemotherapy.  With  a  record  of  about  a  dozen  drugs^  which 
can  be  used  to  cure  or  modify  diseases  caused  by  nearly  a  dozen  different 
protozoa,^  chemotherapy  offers  promise  of  results  which,  with  serum- 
therapy  and  vaccination  in  bacterial  diseases,  will  sharply  limit  the 
ravages  of  the  transmissible  diseases  of  man  and  animals. 

Here  we  must  leave  the  story  of  the  infectious  diseases,  which  has 
occupied  our  attention  from  the  beginning  of  the  third  lecture  to  this 
point,  and  turn  to  a  brief  discussion  of  other  methods  of  modern  re- 
search in  medicine,  those  of  physiological  chemistry,  pharmacology  and 
experimental  pathology,  which  had  their  beginnings  in  the  subjects 
(chemistry,  physiology  and  pathology)  discussed  in  the  second  lecture. 
The  presentation  must,  however,  necessarily  be  but  brief  and  fragmen- 
tary, a  mere  summary,  in  fact,  of  aims  and  methods. 

Physiological  Cliemistry. — The  beginnings  in  this  most  important 
field  of  research  were  in  Liebig's  exact  methods*  for  the  study  of  organic 

'  (I.)  The  arsenic  group:  arsenious  acid,  atoxyl,  acetylatoxyl,  arsenophenyl- 
glycin  and  dioxydiamidoarsenobenzol.  (II.)  Azo-dyestuffs:  trypan-red,  trypan- 
blue  and  trypan-violet.  (III.)  Basic  triphenylmethan  dyestuffs:  parafuchsin, 
methyl-violet   and  pyronin. 

'  Nagana,  surra,  sleeping  sickness,  mal  de  Caderas,  Texas  fever,  chicken 
spirillosis,  relapsing  fever  and  syphilis. 

^  These  appeared  in  the  follovring  publications:  "Instructions  for  the  Chem- 
ical Analysis  of  Organic  Bodies,"  1837;  "Chemistry  in  its  Application  to 
Agriculture  and  Physiology,"  1840;  "Animal  Chemistry  or  Organic  Chemistry 
in  its  Application  to  Physiology  and  Pathology,"  1842;  "Handbook  of  Organic 
Analysis,"  1853.     (Dates  taken  from  early  English  translations.) 


64  MEDICAL   EESEAECH   AND    EDUCATION 

chemistry  and  Wohler's  studies  which  are  famous  on  account  of  his 
synthesis  of  urea.  It  is  usually  stated  that  the  cultivation  of  physi- 
ological chemistry  as  a  distinct  science,  with  independent  institutes  of 
its  own,  dates  from  the  eighth  decade  of  the  past  century,  when  Hoppe- 
Seyler  in  1872  established  his  laboratory  at  Strassburg  and  in  1877 
founded  the  Zeitschrift  f.  physiologische  Chemie.  But  although  this 
period  does  represent  the  first  attempt  to  sharply  separate  laboratories 
of  physiological  chemistry  from  those  of  organic  chemistry,  on  the  one 
hand,  and  of  physiology,  on  the  other,  the  first  independent  chair  of 
physiological  chemistry  was  established  as  my  colleague.  Dr.  John 
Marshall,  informs^  me,  at  the  University  of  Tiibingen  in  1845  and  was 
held  by  Eugen  Schlossberger ;  likewise  Schlossberger's  laboratory  was 
the  first  one  to  be  devoted  exclusively  to  the  study  of  physiological 
chemistry.  It  was  to  this  chair  that  Hoppe-Seyler  was  appointed  in 
1861,  and  which  he  held  until  shortly  after  the  close  of  the  Franco- 
Prussian  war,  when  he  accepted  a  similar  chair  in  the  University  of 
Strassburg. 

Before  and  for  some  time  after  these  events  a  great  volume  of  work 
in  physiological  chemistry  was  done  in  laboratories  of  organic  chemistry 
and  of  physiology;  but  the  events  at  Tiibingen  and  Strassburg  served 
to  concentrate  attention  on  physiological  chemistry  and  eventually  fo 
hasten  the  establishment  of  independent  laboratories.  For  the  first  few 
years  progress  was  slow ;  in  1882,  to  quote  Dr.  Marshall  again,  only  two 
such  independent  laboratories,  those  of  Tiibingen  and  Strassburg, 
existed  in  Germany.  In  the  intervening  thirty  years  the  situation  has 
changed.  Now,  such  laboratories  exist  wherever  adequate  teaching  or 
intelligent  research  in  medicine  is  attempted. 

•  Dr.  Marshall 's  notes  on  the  development  of  physiological  chemistry  at 
Tubingen  are  as  follows:  "In  1816  Dr.  Med.  George  K.  Ludwig  Sigwart  at 
the  request  of  the  Medical  faculty  of  the  University  of  Tubingen  delivered  from 
time  to  time  lectures  on  'Zooehemie, '  but  notwithstanding  that  he  was  made 
professor  extraordinarius  in  1818  he  was  not  provided  with  a  laboratory.  In 
1835  the  professor  was  given  the  use  of  quarters  in  the  laboratory  for  agricul- 
tural and  technical  chemistry  which  was  located  in  the  old  Tubingen  castle.  In 
1845  Eugen  Schlossberger,  a  pupil  of  Liebig  and  of  Heinrich  Rose  was 
called  to  a  professorship  of  physiological  chemistry  in  Tiibingen  which  was  the 
first  independent  chair  of  physiological  chemistry  created  at  a  German  university 
and  the  laboratory  was  the  first  one  to  be  established  as  a  separate  institution. 
From  1861  until  1872  this  chair  was  held  by  Hoppe-Seyler  when  in  1872  he 
resigned  to  accept  a  professorship  of  the  same  title  in  the  newly  revived  univer- 
sity at  Strassburg.  The  laboratory  in  the  old  castle  was  occupied  until  1885 
when  it  was  removed  to  the  new  building  which  had  been  erected  for  the  subject.  * ' 


BESEAECH    IN    MEDICINE  65 

The  early  physiological  chemistry  was  quite  different  from  that 
with  which  we  are  familiar  to-day.  It  was  largely  the  analysis  of  the 
chemical  composition  of  various  body  tissues  and  fluids.  This  early 
conception,  however,  soon  gave  way  to  a  dynamic  conception,  the  idea 
of  function,  and  present-day  investigators  in  physiological  chemistry 
are  concerned  chiefly  with  the  ways  and  means  of  cell  action.  The 
chemical  constitution  of  the  cell,  its  enzymes,  the  methods  by  which  it 
builds  up  complex  bodies  from  simple  substances,  or  disintegrates  a 
compound  to  its  simplest  constituents;  in  brief,  the  problems  of  diges- 
tion, metabolism  and  secretion  in  health  and  disease.  These  are  the 
problems  which  concern  this  science  and  which,  as  its  methods  have 
been  extended  to  include  the  study  of  the  vegetable  kingdom,  as  well  as 
the  lower  forms  of  animal  life,  is  now  more  frequently  known  by  the 
broader  term,  biological  chemistry.  The  dynamic  point  of  view  which 
to-day  characterizes  physiological  chemistry  is  largely  due  to  two  influ- 
ences which  have  come  from  the  outside:  (1)  The  study  of  intramolec- 
ular structure  as  carried  out  on  the  sugars,  purins  and  proteins  by  the 
Fischer  school,  and  (2)  the  study  of  the  nature  of  chemical  reactions, 
as  taught  by  the  modern  school  of  physical  chemistry,  led  by  van't  Hoff. 

Its  fundamental  problems  which  during  recent  years  have  engaged 
the  attention  of  its  best  workers  and  which  still  hold  their  attention  are 
(1)  the  chemical  composition  of  the  protein  molecule,  (2)  the  part 
played  by  ferments  or  enzymes  in  the  metabolic  changes  which  occur 
within  the  cell  and  which  are  responsible  for  the  functions  of  the  various 
organs  and  tissues,  (3)  the  general  problems  of  nutrition  and  the  rela- 
tive values  of  different  food-stuffs,  (4)  the  question  of  the  interrelation 
of  function,  that  is,  of  the  influence  of  the  secretion  of  the  cells  of  one 
organ  or  tissue  on  the  cells  of  a  remote  organ  or  tissue,  (5)  the  mechan- 
ism, from  a  chemical  point  of  view,  of  natural  and  acquired  resistance 
to  disease  and  of  phenomena  associated  with  such  resistance. 

All  of  these  investigations,  it  is  seen,  have  for  their  object  a  better 
knowledge  of  the  mechanism  of  cell  activity. 

Experimental  Pharmacology  or  pharmaco-dynamics,  as  it  is  some- 
times called,  applies  the  methods  of  physiology  and  chemistry  to  the 
study  of  the  action  of  drugs,  poisons  and  other  substances  which  may 
alter  normal  function.  Its  early  development  corresponds  to  the  period 
of  the  application  of  exact  experimental  methods  to  physiology  which, 
as  has  been  shown  in  an  earlier  lecture,  dates  from  about  1840.    Buch- 

6 


66  MEDICAL   BESEAECH    AND    EDUCATION 

heim,  professor  of  materia  medica  at  Dorpat,  established  in  his  own 
house,  in  1849,  a  laboratory  for  the  study  of  pharmacological  problems ; 
somewhat  later  this  laboratory  became  a  part  of  the  University  of  Dor- 
pat  and  was,  therefore,  the  first  laboratory  to  procure  for  pharmacology, 
recognition  as  a  science  of  university  rank.  Furthermore,  Buchheim  in 
1876  in  the  Archiv  f.  experimentelle  Pathologie  und  PharmaJcologie 
(founded  in  1873)  defined  the  methods  and  aims  which  have  guided 
pharmacological  work  for  the  past  thirty-five  years.  He  also  made  the 
first  classification  of  drugs  according  to  their  physiological  action. 

The  proper  study  of  pharmacology  is  all-embracing.  It  includes  not 
only  the  study  of  the  mode  of  action  of  remedial  agents  in  healthy  in- 
dividuals and  the  influence  on  such  action  of  various  abnormal  or  pa- 
thological conditions,  but,  also,  the  effect  of  a  great  variety  of  substances, 
as  bacterial  toxins,  the  secretions  of  venomous  serpents  and  the  prod- 
ucts of  metabolism,  in  short,  all  animal,  vegetable  or  mineral  substances 
in  any  way  capable  of  altering  normal  physiology.  Moreover,  the  study 
of  the  effect  of  these  various  substances  is  not  limited  to  man  and  the 
higher  animals,  but  includes  the  use  of  the  lower  invertebrate  forms, 
bacteria  and  protozoa.  It  is,  therefore,  an  all-inclusive  branch  of  biol- 
ogy, dealing  with  the  "comparative  study  of  the  action  of  chemical 
bodies  on  invertebrate  and  vertebrate  animals."  Its  achievements  are  of 
interest  to  physiology,  to  which  science  it  has  contributed  much,  both  in 
method  and  in  fact;  to  chemistry,  in  that  pharmacology  has  added 
largely  to  the  data  concerning  the  interaction  of  cell  and  chemical  sub- 
stance; and  to  practical  therapeutics,  in  that  it  presents  new  remedies, 
explains  the  action  of  old  remedies  and  defines  the  limitations  of  drug- 
therapy.  Finally  it  has  a  definite  relation  to  the  general  public  welfare 
in  that,  by  its  methods,  it  establishes  procedures  for  determining  the 
potency  of  therapeutic  remedies,  thus  preventing,  on  the  one  hand,  ill 
effect  from  a  drug  of  unusual  power,  and,  on  the  other,  guaranteeing  a 
remedial  agent  of  standard  strength. 

Experimental  Pathology  and  Pathological  Physiology  are  branches 
of  pathology  and  physiology  which,  combining  the  methods  of  both 
these  sciences  with  those  of  chemistry,  attempt,  by  the  study  of  abnormal 
conditions  experimentally  produced,  to  explain  the  disturbance  in  func- 
tion consequent  upon  cell  or  tissue  injury  or  disturbances  in  physiolog- 
ical or  chemical  equilibrium.  Combining  as  they  do  the  methods  of 
several  of  the  medical  sciences,  and  having  for  their  object  the  elucida- 


BESEASCH    IN    MEDICINE  67 

tion  of  definite  problems  in  clinical  medicine,  they  are  essentially  the 
methods  of  a  science  of  clinical  medicine  and  have  aided  materially  in 
the  advance  of  this  branch  of  medicine. 

Such  are  the  methods  and  problems  of  present-day  research  in  medi- 
cine. The  history  of  medicine  teaches  ns  that  new  methods  and  fruit- 
ful hypotheses  may  be  brought  forth  at  any  time ;  new  diseases,  on  the 
other  hand,  can  now  be  expected  only  through  changes  in  social  rela- 
tions and  practises  or  as  the  result  of  new  industries.  Advance,  there- 
fore, would  appear  to  lie  in  the  concentrated  application  of  present 
methods  to  present  problems  and  in  the  application  of  such  new  meth- 
ods, as  may  be  confidently  expected  to  appear  from  time  to  time,  in 
any  science  which  is  so  actively  cultivated  as  is  the  science  of  modern 
medicine. 

In  this  narrative  of  research  medicine  I  have  grouped  the  various 
phases  of  my  presentation  about  men  or  events.  These,  as  Hippocrates 
and  Galen  in  antiquity;  Vesalius  and  his  influence  on  anatomy;  Pare 
and  his  observations  in  surgery;  Harvey,  Hunter  and  Haller  and  their 
more  or  less  isolated  discoveries  in  physiology;  Morgagni  and  his  ob- 
servations in  pathological  anatomy;  and  Jenner  and  his  discovery  of 
vaccination,  represent  the  epoch-making  efforts  of  workers  widely  sepa- 
rated and  more  or  less  isolated.  In  the  early  part  of  the  nineteenth 
century,  Johannes  Miiller,  Liebig  and  Eokitansky  founded  respectively 
the  sciences  of  physiology,  organic  chemistry  and  pathological  anat- 
omy upon  the  basis  of  concentrated  laboratory  effort  and  gave  to  these 
sciences  an  impetus  the  result  of  which  we  recognize  to-day  in  the  im- 
portance which  they  have  attained.  The  main  line  of  advance,  how- 
ever, has  been  in  the  past  70  years,  and  was  made  possible  by  the  study 
of  cells,  through  (1)  the  work  of  Schleiden  on  vegetable  cells  and  of 
Schwann  on  animal  cells  thus  establishing  the  cell  doctrine;  (3)  the 
application  of  this  theory  by  Virchow  to  pathology,  and  (3)  Pasteur's 
conception  of  the  role  played  by  microscopic  cells  in  fermentation  and 
his  application  of  this  to  the  etiology  of  disease.  Out  of  Pasteur's  work 
grew  the  treatment  of  bacterial  diseases  by  vaccines  and  antitoxic  sera, 
and  the  increased  knowledge  of  infectious  diseases  gained  by  the  study 
of  bacteriology,  led  to  the  search  for  protozoa  as  causes  of  disease  and 
the  demonstration .  of  the  etiological  importance  of  the  latter,  led,  in 
turn,  to  the  development  of  Ehrlich's  chemotherapy  as  a  means  of  com- 


68  MEDICAL   BE  SEARCH   AND    EDUCATION 

bating  protozoan  disease.  But  while  this  was  the  main  line  of  advance 
we  have  seen  how  Pasteur  influenced  surgery  through  Lister,  and  how 
anesthesia,  through  the  efforts  of  Morton  came  also  to  aid  this  science. 
So,  likewise,  physiological  chemistry  came  into  being,  indirectly  as  a  re- 
sult of  Liebig's  work,  but  more  directly  as  a  result  of  the  needs  of 
physiology  for  a  better  understanding  of  cell  composition  and  enz3rme 
action,  and,  finally,  both  physiology  and  physiological  chemistry  con- 
tributed to  the  establishment  of  pharmacology  and  experimental  pathol- 
ogy. Medicine,  in  the  sense  of  internal  medicine,  benefited  by  each  and 
every  advance  in  each  and  every  one  of  its  contributory  branches,  and, 
through  the  application  of  the  principles  of  physics  and  chemistry  to 
methods  of  diagnosis,  gained  its  present  large  equipment  of  instruments 
of  precision  and  means  of  exact  interpretation ;  surgery  in  like  manner 
gained  the  X-ray  and  many  technical  and  mechanical  procedures;  and 
preventive  medicine,  utilizing  the  knowledge  obtained  through  bacter- 
iology, protozoology,  immunity  and  chemistry,  shares,  with  the  science 
of  engineering,  the  glory  of  promoting  in  greater  degree  than  all  other 
factors  the  social  and  industrial  welfare  of  humanity. 

The  facilities  and  opportunities  possessed  by  American  universities 
for  the  continuance  of  this  progress  will  be  the  subject  of  the  fifth 
lecture. 


LECTURE    V 

Medical  Eesearch  in  American  Universities;  Present  Facili- 
ties, Needs  and  Opportunities 

If  the  preceding  lectures  have  a  special  value,  it  is  in  indicating, 
on  the  basis  of  past  experience,  the  methods  and  mode  of  approach, 
which  will  presumably  yield  the  greatest  measure  of  success  in  the 
investigation  of  present  and  future  problems.  Looked  at  in  this  light 
what  I  have  cited  of  the  past  shows  four  important  aspects: 

1.  The  epoch-marking  labors  of  isolated  individuals  working  inde- 
pendently. 

2.  The  application  of  the  exact  methods  of  physics,  chemistry  and 
biology  to  medicine. 

3.  The  development  of  laboratories  for  the  organized  and  intensive 
investigation  of  the  various  problems  of  medicine. 


BESEAECE   IN    MEDICINE  69 

4.  The  idea  of  diminishing  suffering  and  ameliorating  social  con- 
ditions. 

The  first  of  these  factors  naturally  suggests  the  names  of  Vesalius, 
Pare,  Harvey,  Hunter,  Jenner,  Morgagni  and  Haller.  Some  of  these 
may  have  been  influenced  by  antecedent  work  as  Vesalius  by  Herophilus 
and  Erasistratus ;  Harvey  by  his  forerunners,  who  studied  the  circula- 
tion of  the  blood ;  and  all,  perhaps,  by  the  old  teachings  of  Hippocrates 
or  the  experimental  side  of  Galen's  work,  but  the  actual  achievement 
of  each,  whether  the  result  of  chance  suggestion,  original  conception, 
or  keen  observation,  was  the  fruit  of  labors  unassisted,  prosecuted  with 
difficulty,  and  in  most  instances  in  opposition  to  the  traditions  of  the 
profession.  Such  independent  effort,  though  most  prominent  in  the 
period  previous  to  the  year  1800,  always  has  had  and  always  will  have 
a  place  in  medicine.  This  is  seen  in  the  efforts  of  the  individual,  even 
after  medicine  was  influenced  by  its  ancillar}'^  sciences  and,  indeed,  in 
the  days  of  organized  laboratory  effort.  In  this  connection,  one  recalls 
Sir  George  Baker's  demonstration  that  a  form  of  colic,  epidemic  in 
character,  occurring  in  Devonshire,  England,  was  to  be  explained  as  a 
poisoning  by  lead;  Captain  Cook's  conquest  of  scurvy;  Auenbrugger's 
invention  of  the  method  of  percussion;  Laennec's  invention  of  the 
stethoscope;  the  theory  announced  independently  by  Holmes  and  by 
Semmelweis  of  the  transmission  of  puerperal  fever  and  many  other 
independent  efforts  in  the  practise  of  surgery  and  medicine,  as  those 
with  which  we  associate  the  names  of  Pinel,  McDowell,  O'Dwyer  and 
Tnideau. 

Modern  effort  in  research  in  medicine,  however,  as  in  science  gen- 
erally, is,  it  must  be  admitted,  organized  laboratory  effort,  and  upon 
this  type  of  effort  present-day  progress  would  seem  to  depend.  Never- 
theless, the  individual  is  as  important  as  ever,  for  "it  goes  without 
saying  that  laboratory  buildings  alone,  even  when  adequately  equipped 
and  with  a  liberal  maintenance  budget,  are  far  less  important  than  the 
men  who  work  in  them"  (Barker),  but  the  laboratory  now  offers  to 
the  individual,  with  original  conceptions  or  special  talents,  advantages, 
facilities  and  opportunities  which,  by  aiding  and  supplementing  the 
work  of  the  individual,  render  isolated  effort  unnecessary,  time-con- 
suming and  often  futile. 

Under  the  second  head,  the  influence  of  physics,  chemistry  and 
biology,  fall  such  men  as  the  English  physicists  and  chemists  and  the 


70  MEDICAL   EESEAECR   AND    EDUCATION 

French  academicians — Boyle,  Cavendish,  Priestley,  Galvani,  Faraday, 
Tyndall,  Lavoisier,  Gay-Lussac  and  Berzelius.  A  more  direct  influence 
is  seen  in  the  entrance  of  Pasteur,  a  chemist,  into  the  field  of  etiology ; 
of  Ehrlich,  a  physician,  but  chemically  trained,  into  the  field  of  im- 
munity and  specific  chemical  afiinities;  and  of  Metchnikoff,  applying 
the  methods  of  the  biologist  to  the  problems  of  pathology.  Likewise 
Liebig  and  Wohler  and  organic  chemistry;  Hoppe-Seyler  and  physiolog- 
ical chemistry;  Arrhenius  and  physical  chemistry,  Darwinism,  Men- 
delism,  all  have  had  their  influence,  and  the  methods  and  views  they 
represent  have  been  taken  over  by  medicine  and  applied  to  the  solution 
of  its  problems. 

The  influence  of  physics  and  chemistry  in  establishing  the  third 
factor — organized  laboratory  effort  in  special  fields  of  medicine — we 
have  seen  in  the  beginnings  of  laboratory  research  in  the  second  quarter 
of  the  past  century.  Virchow  at  the  time  he  was  urging  the  establish- 
ment of  pathological  laboratories  epitomized  the  history  of  organization 
in  medical  effort  as  follows : 

As  in  the  seventeenth  century  anatomical  theaters,  in  the  eighteenth,  clinics, 
in  the  first  part  of  the  nineteenth,  physiological  institutes,  so  now  the  time  has 
come  to  call  into  existence  pathological  institutes  and  to  make  them  as  accessible 
as  possible  to  all. 

Since  then,  the  laboratory  idea  has  spread  rapidly ;  not  alone  labora- 
tories of  pathology  have  been  founded,  but  also  laboratories  of  bac- 
teriology, hygiene,  physiological  chemistry,  pharmacology  and  every 
branch  of  endeavor  promising  advance  in  the  science  of  medicine.  Not 
only  have  such  laboratories  come  into  existence  in  university  schools  of 
medicine  and  in  hospitals,  but  many  independent  laboratories  for 
research  alone  have  been  founded  in  the  large  medical  centers,  as  the 
Pasteur  Institute  in  Paris  (1888),  the  Imperial  Institute  for  Experi- 
mental Medicine  in  St.  Petersburg  (1890),  the  Institute  for  Infectious 
Diseases  in  Berlin  (1891),  the  Lister  Institute  for  Preventive  Medicine 
in  London  (1891),  the  Institute  for  Experimental  Therapeutics  in 
Frankfort  (1896),  the  Eockefeller  Institute  for  Medical  Eesearch  in 
New  York  (1901),  the  Memorial  Institute  for  Infectious  Diseases  in 
Chicago  (1902),  the  Henry  Phipps  Institute  for  the  Study,  Treatment 
and  Prevention  of  Tuberculosis  in  Philadelphia  (1903).  Likewise, 
municipal,  state,  provincial  and  national  laboratories,  devoted  to  work 
concerned  with  the  public  health,  have  been  established.     Some,  follow- 


BESEAMCH    IN    MEDICINE  71 

ing  the  example  of  the  first  laboratory  of  h^'-giene,  that  of  Pettenkoffer, 
founded  by  the  Bavarian  government  in  1873,  have  been  most  active  in 
investigation;  others  are  devoted  mainly  to  the  routine  work  necessary 
for  the  conservation  of  the  public  health.  How  essential  laboratories 
of  the  latter  type  are  is  shown  by  the  fact  that  several  states,  New  York 
among  the  first,  have  established  county  or  district  laboratories  to  care 
for  the  problems  of  communities  distant  from  the  state  laboratory  and 
the  laboratories  of  the  larger  cities. 

So  also  laboratories  as  an  integral  part  of  hospitals,  the  so-called 
clinical  laboratories — the  first  of  which  was  established  by  Ziemssen  in 
Munich  about  1886 — have  become  a  necessary  part  of  every  hospital 
which  makes  any  pretense  of  accurate  diagnosis  and  adequate  therapy. 
The  list  might  be  extended  to  include  also  laboratories  devoted  to  special 
diseases,  as  cancer  and  tuberculosis,  diseases  peculiar  to  the  tropics,  and 
diseases  of  animals,  or  to  special  branches  as  surgical  pathology,  neuro- 
pathology and  psychopathy.  This  wonderful  extension  of  the  labora- 
tory idea  in  medicine  dates  only  from  the  simple  beginnings  of  Purkinje 
and  Liebig  in  1824-25.  At  the  present  day,  Germany  alone  is  said  to 
have  over  two  hundred  such  medical  institutes,  and  to  this  policy  of 
establishing  laboratories  must  be  ascribed  her  leadership  in  the  medical 
sciences  since  the  third  decade  of  the  past  century. 

From  this  brief  recapitulation  of  the  important  influences  affecting 
research  in  medicine,  only  one  conclusion  is  deducible;  that  although 
the  individual  will  continue  to  be  the  most  significant  factor  in  the 
situation,  it  is  unquestionable  that  his  perception  will  be  constantly 
stimulated,  his  imagination  quickened  and  his  hands  aided,  by  the 
opportunities,  ideals  and  facilities  of  the  laboratory.  In  the  laboratory 
only  can  "  the  prepared  mind  "  of  Pasteur's  adage  ("  In  the  fields  of 
observation  chance  favors  only  the  prepared  mind")  be  properly  fos- 
tered. It  is  in  the  laboratory,  and  under  this  term  I  include  the  prop- 
erly conducted  hospital  as  the  laboratory  of  clinical  medicine,  that 
medicine  keeps  in  close  touch  with  new  discoveries  in  physics,  chemistry 
and  biology,  the  second  of  the  three  important  factors  we  have  discussed. 
The  situation  in  regard  to  the  auxiliary  sciences  has  not  changed 
since  the  time  of  Liebig,  Miiller  and  Virchow.  The  investigator  in  the 
laboratory  and  the  investigator  in  the  hospital  still  look  to  these  sci- 
ences for  assistance  and  eagerly  apply  the  discoveries  in  each  of  these  to 
his  own  problems.     The  result  is  a  decided  advantage  to  medicine,  not 


72  MEDICAL   RESEABCH   AND   EDUCATION 

only  in  that  this  revivifying  and  suggestive  influence  leads  to  accel- 
erated progress  in  the  science  and  art  of  medicine,  but  also  in  that  it 
directly  influences  the  health  and  therefore  the  welfare,  commercial  and 
social,  of  the  community. 

This  brings  us  to  the  fourth  factor  which  has  influenced  medical 
research  in  the  past  and  should — indeed  must — continue  to  be  an  ever- 
increasing  influence  in  the  future — the  desire  to  ameliorate  social  condi- 
tions, by  diminishing  the  causes  of  physical  and  mental  ills.  This,  in  a 
word,  is  the  desire  for  social  service;  the  impulse  which  actuated  all  of 
Pasteur's  work,  and  which  he  himself  expressed  as  the  desire  to  con- 
tribute "  in  some  manner  to  the  progress  and  welfare  of  humanity." 
It  is  not  sufficient  that  the  individual  as  an  investigator  should  be 
actuated  only  by  his  ambition  and  his  investigations,  or  alone  by  his 
desire  for  exact  abstract  knowledge.  If  medical  research  is  to  be  a 
vitalizing,  reforming,  uplifting  factor,  not  only  for  the  practise  of  medi- 
cine, but  for  the  good  of  the  community  at  large,  then  the  whole  man 
must  be  interested,  heart  and  soul,  not  only  in  the  technical  and  ab- 
stract results  of  his  problems,  but  in  their  practical  applications  to 
medical  and  social  conditions.  What  does  this  mean  for  medical 
research?  That  the  laboratory  shall  be  not  only  the  brains,  but  the 
hands,  of  the  community !  It  must  recognize  not  only  the  problems  of 
the  community,  but,  solving  the  technical  aspects  of  these  problems, 
must  demonstrate  how  they  are  to  be  met  and  cared  for.  In  short,  the 
investigator  in  medicine  must  be  stirred  by  not  only  an  abstract  interest 
in  human  ills,  but  a  direct  interest  in  the  problems,  prophylactic  or 
therapeutic,  hygienic  or  social,  of  the  community,  with  all  its  differen- 
tiation into  industrial,  commercial  and  domestic  activities,  of  which  he 
is  a  member. 

If  I  am  right  concerning  the  importance  of  these  various  influences 
it  would  appear  safe  to  conclude  that  progress  in  medicine  may  be 
expected  in  the  future,  as  in  the  past  fifty  years,  through  the  opportuni- 
ties afforded  the  well-trained  individual  in  well-equipped  and  well-organ- 
ized laboratories,  through  the  cultivation  of  the  methods  of  auxiliary 
sciences  and  through  the  ideal  of  social  service.  And  here  I  may  say 
that  in  using  the  term  "laboratory"  I  do  not  limit  the  term  to  the 
ordinary  sense,  but  include  the  idea  of  research  work  in  the  hospital. 
One  of  the  great  influences  of  the  application  of  the  laboratory  idea  to 
medicine  has  been  the  recognition  of  the  principle  that  hospitals  should 


BESEAECE   IN   MEDICINE  73 

be  utilized  not  only  for  the  care  of  the  sick,  which  is  the  first  and  most 
important  function  of  a  hospital,  but  for  purposes  of  teaching  and  in- 
vestigation as  well.  "With  such  a  conception,  a  hospital  becomes  the 
laboratory  of  the  science  of  clinical  medicine  and  in  it  the  clinician  as 
an  investigator  studies  disease  by  the  same  exact  methods  as  are  utilized 
in  any  other  laboratory. 

If,  then,  the  laboratory  and  the  hospital  are  the  tangible  means  of 
progress  in  medicine  which  our  universities  offer,  how  may  research  in 
the  university  be  best  served  and  what  advantage  does  the  university 
gain  by  fostering  research  ? 

By  limiting  the  scope  of  this  discussion  to  the  university  I  do  not 
wish  it  to  be  thought  that  I  desire  to  minimize  the  importance  of  the 
work  done  by  independent  institutions  for  research  or  by  state  and  city 
laboratories.  The  important  work  done  by  the  Eockefeller  Institute  for 
Medical  Eesearch,  for  example,  has  placed  this  institution  in  one  group 
with  the  Pasteur  Institute,  Koch's  Institute  in  Berlin,  Ehrlich's  Insti- 
tute in  Frankfort  and  the  Imperial  Institute  for  Experimental  Medi- 
cine in  St.  Petersburg.  The  character  of  its  present  staff,  including  as 
it  does,  your  former  professor  of  physiology,  promises  as  great  work  for 
the  future  as  has  been  accomplished  in  the  past.  Likewise,  the  Memorial 
Institute  for  Infectious  Diseases  in  Chicago  and  the  Henry  Phipps 
Institute  of  Philadelphia  are  doing  valuable  work  in  the  study  of  the 
diseases  for  the  investigation  of  which  they  were  founded.  Such  insti- 
tutions point  the  lesson  of  the  economic  importance  of  research,  which, 
if  fully  grasped  by  the  public,  would  guarantee  the  support  of  inde- 
pendent institutions  in  every  large  center  or  wherever  special  facilities 
for  the  study  of  particular  diseases  could  be  found.  Moreover,  all  these 
institutions  have  recognized  the  necessity  of  an  intimate  connection  with 
a  hospital  in  order  to  render  their  investigations  most  effective. 

So  also  laboratories  of  state  or  city  departments  of  health  as  of  the 
state  of  Massachusetts  and  the  state  and  city  of  New  York  and  the 
Hygienic  Laboratory  of  the  Public  Health  and  Marine  Hospital  Service, 
supported  by  the  national  government,  have  made  original  investiga- 
tion of  the  infectious  diseases  an  important  and  often  major  part  of 
their  work.  In  addition  the  Hygienic  Laboratory  has  made  most  im- 
portant investigations  in  pharmacology.  Other  non-university  research 
institutions,  as  the  New  York  State  Laboratory  for  the  investigation  of 
cancer,  the  Rockefeller  Commission  for  the  Study  of  Hook-worm  Dis- 


74  MEDICAL   BESEAECH   AND    EDUCATION 

ease,  Trudeau's  laboratory  at  Saranac  for  the  study  of  tuberculosis  and 
that  for  the  study  of  problems  of  nutrition  supported  by  the  Carnegie 
Institution  at  Boston,  are  of  great  importance.     Such  institutions,  and 
I  have  not  exhausted  the  list,  devoted  to  the  investigation  of  the  prob- 
lems of  medicine  and  without  affiliation  with  teaching  institutions  must 
be  counted  as  among  the  most  important  factors  in  our  social  system. 
Research  in  the  medical  school  or  the  hospital,  on  the  other  hand, 
has  developed  slowly  and  has  been  in  most  institutions  a  matter  of 
secondary  importance.     The  reason  for  this  is  not  difficult  of  demon- 
stration when  one  remembers  that  even   schools  of  university  rank 
emerged  only  a  short  time  ago  from  the  proprietary  state  and  that  most 
physicians  just  past  middle  age  can  remember  the  two-  and  three-year 
course.      Large  classes,  the  belief  in  the  didactic  lectures,  and  the 
expense  of  laboratory  equipment  retarded  the  development  of  proper 
laboratory  facilities  and  therefore  the  development  of  men  trained  to 
exact  methods  in  the  medical  sciences.     Likewise  in  the  clinic  the  ideal 
teacher,  with  a  few  notable  exceptions,  was  the  busy  consultant  who 
devoted  only  a  few  hours  of  oratorical  effort  to  clinical  instruction  and 
who  disdained  investigation  as  beneath  the  notice  of  a  practical  physi- 
cian— an  ideal  which  still  holds  in  many  of  the  more  conservative 
schools  and  is  responsible  for  the  slow  progress  in  the  development  of 
a  science  of  clinical  medicine.     This  type,  however,  is  rapidly  passing 
away  and  another  generation  may  look  back  upon  it  as  we  do  upon  the 
age  of  the  proprietary  school,  the  two  years'  course  and  the  amphi- 
theater lecture. 

It  is  not  my  intention  to  trace  the  beginnings  of  research  in  medical 
laboratories  in  this  country,  or,  fascinating  as  it  would  be,  if  time 
allowed,  to  analyze  early  conditions  and  influences.  A  few  men,  how- 
ever, stand  out  prominently,  as,  for  example,  Leidy,  of  Pennsylvania, 
teacher  of  anatomy  and  investigator  in  comparative  anatomy,  one  of 
the  greatest  of  American  investigators  in  general  biology,  and  Bowditch, 
who  offered  at  Harvard  in  the  seventies  the  first  opportunity  for  organ- 
ized research  in  physiology  in  this  country.  Laboratories  of  anatomy, 
that  is,  dissecting  rooms,  had  always  existed,  but  the  modern  type  of 
anatomical  investigation  in  anatomy  is  due  to  the  influence  of  Minot,  of 
Harvard,  and  Mall,  of  Hopkins.  Likewise,  laboratories  of  inorganic 
chemistry  and  so-called  medical  chemistry  existed,  but  research  in 
physiological  and  biological  chemistry  goes  back  only  to  Chittenden,  of 


BESEAUCE    IN    MEDICINE  75 

Yale,  and  Macallum,  of  Toronto;  Delafield,  Welch  and  Prudden  in 
New  York  and  Fitz  in  Boston  appear  to  have  been  among  the  first  to 
control  university  laboratories  of  pathology  in  which  at  least  a  few 
men  gave  much  of  their  time  to  teaching  or  investigation,  but  the 
great  impetus  to  research  in  pathology  and  bacteriology  coincides  with 
Welch's  affiliation  with  the  Johns  Hopkins  Hospital,  and  experimental 
pathology  as  a  sustained  effort  was  first  broadly  cultivated  by  Flexner. 
Investigation  in  pharmacology  by  modem  exact  methods,  in  laboratories 
devoted  to  that  subject,  is  the  result  of  the  labors  of  "Wood  at  Pennsyl- 
vania, of  Cushny  at  Ann  Arbor,  of  Abel  at  Baltimore,  of  Herter  in  New 
York  and  of  Sollman  in  Cleveland.  The  first  university  institute  of 
hygiene  was  that  established  at  Pennsylvania  in  1892.  These  are  the 
names  which  the  compiler  of  American  medical  history  one  hundred 
years  from  now  will  compare,  in  discussing  the  development  of  our 
laboratories,  with  those  of  the  period  of  1820  to  1860  in  Germany. 
Why  ?  Because  these  men  established  not  merely  teaching  laboratories, 
but  stimulated  investigation,  inculcated  exact  methods  and  trained  men, 
and  thus  made  an  impression  upon  the  medicine  of  their  time.  This  is 
true  not  merely  of  their  influence  in  furthering  research,  but  of  their 
influence  in  advancing  the  fundamental  principles  of  proper  medical 
education.  As  soon  as  it  was  demonstrated  that  laboratories  were 
indispensable  to  proper  medical  education,  the  day  of  the  medical  school 
worthy  of  university  rank  arrived  and  the  proprietary  medical  school 
as  an  important  factor  in  medical  education  became  a  thing  of  the  past. 
Moreover,  as  I  have  intimated,  the  principle  of  laboratory  instruction 
and  laboratory  research  which  gave  to  laboratory  eSort  the  strongest 
place  in  the  curriculum  has  had  a  distinct  effect  on  the  clinical  teaching 
of  medicine  and  surger}',  so  that  in  some  of  our  better  schools  the  indi- 
vidual student  now  has  that  opportunity  for  immediate  contact  with 
the  patient  which  allows  the  direct  exercise  of  his  powers  of  observation, 
of  the  use  of  instruments  of  precision  and  of  exact  procedures  which 
assure  the  acquirement  not  only  of  knowledge,  but  power  to  obtain 
knowledge.  The  result  is  the  recognition  of  the  clinic  as  a  place  for  the 
exercise  of  exact  methods  in  the  teaching  of  the  clinical  branches  and 
in  the  investigation  of  disease.  Both  fields  of  activity,  the  hospital  and 
the  laboratory,  now  have  the  "  common  purpose  to  advance  medical 
knowledge  and  thereby  bring  healing  to  the  nations." 

With  this  conception  of  a  common  purpose  guiding  medical  educa- 


76  MEDICAL   BESEABCH    AND    EDUCATION 

tion  and  medical  research  and  with  the  present  unanimity  of  opinion 
concerning  the  absolute  necessity  of  control  of  a  hospital  by  the  univer- 
sity, the  duty  of  the  latter  to  research  is  clear.  If  the  purpose  of  the 
machinery  of  medical  education  is  to  "  bring  healing  to  the  nations  " ; 
if  "  the  business  of  medicine  is  to  get  people  out  of  difficulties  through 
the  application  of  science  and  dexterity  manual  and  psychical"  (Cabot), 
then  it  is  the  duty  of  the  university  not  only  to  teach  known  principles 
and  methods,  but  to  advance  knowledge  and  methods  by  research. 

It  is  futile  to  say  that  it  is  sufficient  to  teach  and  to  utilize  known 
methods  for  freeing  peoples  from  difficulties,  for  the  mere  statement  of 
such  an  attitude  implies  that  an  obligation  exists  to  extend  known 
methods  or  invent  new  ones  in  the  hope  of  overcoming  difficulties, 
acknowledged  to  be  at  present  without  remedy.  The  ethical  force  of 
this  statement  can  not  be  denied.  To  teach  a  subject  implies  the 
attempt  to  diffuse  the  available  knowledge  of  that  particular  subject 
matter  among  a  number  of  people  for  their  good  as  well  as  for  the  good 
of  the  community  in  which  they  live  and  work;  equally  true  it  is  that 
such  an^attempt  to  teach  available  knowledge  imposes  upon  the  teacher 
the  obligation  to  leave  untried  no  means  by  which  the  knowledge  of  his 
subject  may  be  increased.  It  is  not  the  privilege  of  the  teacher  to  leave 
this  extension  of  knowledge  to  others.  His  profession  of  ability  to 
teach  a  particular  subject  carries  with  it  his  obligation  to  the  group  or 
community  he  serves,  of  adding  to  his  subject,  knowledge  of  which  they 
may  avail  themselves.  If  this  applies  to  the  individual  teacher,  how 
much  more  forcibly  does  it  apply  to  the  university  with  its  ever-widen- 
ing community  and  ever-increasing  interests? 

But  ethics  are  frequently  set  aside  in  our  practical,  every-day  world 
and  even  if  they  are  not  the  great  expense  of  maintaining  laboratories 
and  a  hospital,  an  expense  greatly  increased  if  research  is  properly 
prosecuted,  causes  university  presidents  and  trustees  to  ask  what  are  the 
practical  advantages  of  research  to  the  university;  and  in  those  institu- 
tions which  are  supported,  in  part  or  entirely,  by  the  state,  this  question 
must  be  squarely  met. 

In  presenting  the  arguments  in  favor  of  research  in  the  university, 
I  will  consider  only  conditions  in  this  country  and  will  not,  though  it 
would  greatly  strengthen  the  argument,  utilize  the  experience  of  the 
German  universities.  One  of  the  most  important  advantages,  and  one 
which  should  appeal  to  those  controlling  the  policy  of  a  university,  is 
the  influence  on  the  student. 


BESEAECH    IN   MEDICINE  77 

If  one  examines  courses  in  the  same  subject  in  a  number  of  schools, 
it  is  found  that  those  which  are  best  presented  are  under  the  control  of 
men  actively  engaged  in  research  work.  Such  men  are  alive  to  the 
advantages  of  new  methods  in  their  own  subject  and  of  new  ways  of 
applying  old  methods.  Ever  thinking  and  pondering  about  methods  of 
acquiring  new  knowledge  for  themselves  and  their  science,  they  appre- 
ciate better  than  does  the  non-investigator  that  which  will  aid  the 
student  to  acquire  knowledge,  and  in  their  teaching  they  bring  to  bear 
on  the  problems  which  the  student  has  to  face  the  same  methods  of 
attack  which  they  use  in  their  own  researches.  Under  these  men  are 
assistants  of  the  same  point  of  view,  who,  ever  enthusiastic  about  their 
duties  as  teachers,  nevertheless  find  time  for  research.  And  it  is  of 
further  interest  that  in  these  departments  assistants  do  not  long  con- 
tinue in  a  subordinate  place,  or  at  least  if  they  do  it  is  of  their  own 
desire,  for  they  are  early  called  to  independent  positions  in  other  insti- 
tutions. On  the  other  hand,  one  finds  that  the  men  who  confine  their 
teaching  to  perfunctory  routine  laboratory  courses,  with  a  profusion  of 
lectures,  are  the  men  who  never  or  only  occasionally  contribute  to  the 
literature  of  their  science. 

In  these  departments,  too,  the  teaching  is  a  routine  which,  so  the 
assistants  say,  gives  no  time  for  investigation;  and  so  they  remain 
assistants  indefinitely.  So,  likewise,  it  is  with  the  student  taught  under 
these  two  conditions.  The  student  who  knows  that  he  is  working  in  a 
department  actively  emphasizing  new  methods  and  striving  to  develop 
new  truths,  knows  that  his  instruction  is  presented  on  the  same  basis, 
and  thus  receives  that  stimulus  and  inspiration  which  ensures  his  ap- 
proaching clinical  medicine  with  a  proper  appreciation  of  the  scientific 
method.  The  student  under  the  method  of  the  non-investigator,  on  the 
contrary,  has  no  incentive  other  than  that  of  acquiring  a  knowledge 
sufiicient  to  allow  him  to  pass  an  examination. 

An  allied  argument  lies  in  the  fact  that  the  medical  school  that 
fosters  research  attracts  the  best-trained  men  as  students.  We  have,  as 
is  well  known  to  many  of  you,  a  medical  school  in  this  country  which 
has,  for  several  years,  arbitrarily  selected  from  a  large  number  of  pros- 
pective matriculants  the  certain  definite  number  which  it  desires;  the 
rest,  sometimes  equal  to  50  per  cent,  of  those  accepted,  go  elsewhere. 
Now  this  school  has  the  highest  of  entrance  requirements  and  perhaps 
the  smallest  alumni  body  of  any  prominent  school  in  the  country.     It 


78  MEDICAL   EESEABCH   AND    EDUCATION 

is  not  therefore  a  question  of  easy  entrance  or  of  the  loyal  influence  of 
alumni.  Nor  is  it  a  question  of  better  laboratory  and  hospital  facili- 
ties, for  other  schools  have  equally  good  equipment  in  both  respects. 
Likewise  it  is  not  a  question  of  geographic  location  or  center  of  popula- 
tion. The  enviable  position  of  this  school  is  due  solely  to  the  policy  of 
combining  research  with  teaching  and  of  appointing  to  its  stafE  teach- 
ers who,  with  few  exceptions,  are  also  investigators. 

My  contention  that  research  in  the  medical  school  has  important 
practical  advantages  to  the  university  is,  therefore,  not  visionary  or 
theoretical.  A  policy  which  attracts  the  better-trained  class  of  stu- 
dents, which  improves  the  character  of  the  instruction,  which  stimulates 
the  student  to  a  better  type  of  individual  effort,  and  which  enhances  the 
standing  of  the  university  in  the  community  and  the  nation  is  a  policy 
which  can  not  be  ignored  by  university  president,  trustees  or  faculty. 

Another  phase  of  this  subject  is  the  duty  of  the  university  in  public 
health  and  other  medical  matters  of  interest  to  the  community  and 
essential  to  its  welfare.  State  and  city  have  always  felt  at  liberty  to 
call  university  experts  to  their  aid  in  the  solution  of  problems  of  admin- 
istrative'policy  and  public  weal.  Not  infrequently,  as  in  the  case  of 
Harvard  University  and  the  Massachusetts  State  Department  of  Health 
and  that  of  New  York  City  and  New  York  University,  the  university 
shares  with  the  state  or  city  the  service  of  expert  investigators  in  the 
preparation  of  curative  sera  and  the  study  of  new  methods  of  combating 
disease.  In  some  states  the  university  laboratories  of  hygiene,  bac- 
teriology or  pathology  are  the  research  laboratories  of  the  state.  The 
problems  of  agriculture,  of  animal  industry  and  veterinary  medicine 
are,  in  the  states  of  the  middle  west,  largely  under  the  control  of  uni- 
versity laboratories.  It  is  not  my  desire  to  discuss  in  its  general  appli- 
cation the  question  of  the  part  of  the  university  in  social  service  but 
that  the  mid-western  state  universities  have  solved  this  question  in  the 
matter  of  animal  and  plant  disease  and  in  agricultural  and  certain 
industrial  problems  is  evident  from  the  occasional  references  to  the 
university  as  "  the  people's  organized  instrument  of  research  "  or  "  the 
scientific  adviser  of  the  state."  This  idea  of  social  service  must,  and 
already  does,  to  some  extent,  include  the  study  of  diseases  of  man.  To 
what  extent  the  latter  shall  develop  in  state  universities  depends  upon 
the  liberality  of  the  state,  or,  as  in  non-state  universities,  upon  endow- 
ment by  individuals.     This  matter  of  endowment  is  the  crux  of  the 


BESEAECH   IN   MEDICINE  79 

research  problem  in  its  connection  with  the  university.  It  is  no  longer 
possible  for  a  medical  school  to  be  supported  by  the  fees  of  its  students. 
In  the  old  days  of  the  proprietary  school,  when  instruction  was  almost 
entirely  didactic,  and  the  only  laboratory  work  was  the  dissecting 
room,  with  perhaps  a  room  for  workers  in  inorganic  chemistry  and  the 
simple  procedures  of  so-called  medical  chemistry,  fees  sufficed  and  the 
faculty  could  pocket  a  good  dividend.  The  increased  cost  of  laboratory 
instruction  in  its  many  phases,  the  increase  of  equipment,  of  assistants 
and  attendants,  have  made  this  impossible  and  have  forced  the  medical 
schools  to  the  shelter  of  universities  which  have  resources  sufficient  to 
support  medicine.  But  even  with  this  aid,  few  schools  have  sufficient 
funds  to  satisfy  the  demands  of  adequate  instruction  and  leave  a  balance 
for  investigation.  The  result  has  been  that  universities  seek  special 
endowment  for  specific  lines  of  investigation  and  it  is  unquestionably 
along  such  special  lines  that  an  increase  in  the  facilities  for  research  is 
to  be  expected. 

A  consideration  of  the  special  departments  of  research  now  exist- 
ing, of  the  factors  determining  their  establishment,  and  of  the  influence 
such  departments  have  exerted  may  be  worth  while.  It  has  been  said 
by  some  authority  on  university  affairs,  that  "the  best  way  to  get  en- 
dowment is  to  deserve  it";  and  this  is  the  principle  which  actuates  a 
not  inconsiderable  body  of  men  scattered  over  this  country  who  by 
their  efforts  are  attempting  to  bring  forcibly  before  the  public  and 
university  trustees  the  value  of  investigation,  particularly  of  the  pre- 
ventable diseases,  as  a  necessary  and  dignified  type  of  university  effort. 

It  is  of  interest  to  note  the  various  ways  in  which  research  chairs 
or  departments  have  been  established.  Some  have  been  the  result  of 
the  multiplication  of  chairs  devoted  to  one  general  subject,  as  at  Har- 
vard, which  has  in  the  medical  school  chairs  of  comparative  pathology, 
comparative  physiology  and  comparative  anatomy,  each  of  which  is 
quite  distinct  from  the  chairs  responsible  for  the  fundamental  under- 
graduate instruction  in  pathology,  physiology  and  anatomy.  The  es- 
tablishment of  these  chairs,  in  part  through  special  endowment,  has 
greatly  increased  the  facilities  and  time  available  for  research  in  these 
fundamental  branches  and  for  special  or  more  detailed  instruction  in 
the  various  activities  which  they  represent.  Likewise  the  splitting  off 
from  bacteriology  of  independent  departments  of  preventive  medicine 
(Harvard  and  Washington  universities)  has  increased  the  opportunities 


80  MEDICAL    RESEARCH    AND    EDUCATION 

for  the  study  not  only  of  the  infectious  diseases,  but  also  of  those  due  to 
industrial  conditions,  to  poverty  and  insufficient  methods  of  preparing 
and  handling  food-stuffs. 

Of  similar  origin  are  the  departments  established  recently  at  Penn- 
sylvania and  Tulane  for  the  study  of  tropical  diseases.  So  also  at 
Harvard  an  opportunity  for  similar  effort  has  been  made  possible 
through  the  endowment  of  a  traveling  professorship  in  the  department 
of  bacteriology.  In  the  same  way  increased  facilities  for  investigation 
in  chemistry  has  been  brought  about  by  the  founding  of  departments 
devoted  to  physiological  chemistry,  independent  of  the  older  chairs  of 
chemistry  and  toxicology;  by  the  recognition  of  a  sphere  of  usefulness 
in  experimental  pharmacology  independent  of  materia  medica  and  ap- 
plied therapeutics;  by  departments  of  experimental  pathology  and 
pathological  physiology,  neuro-pathology  and  surgical  pathology  co- 
operating with  or  independent  of  the  traditional  departments  of  path- 
ology ;  by  the  evolution  in  surgical  teaching  and  research  of  laboratories 
of  experimental  and  veterinary  surgery,  and,  in  our  hospitals,  of  labora- 
tories of  clinical  pathology.  These  departments,  in  most  instances, 
having  some  instructorial  duties,  have  an  enormous  influence  in  further- 
ing research  and  in  indicating  the  need  for  its  extension.  For  the  most 
part,  whether  founded  on  special  endowment  or  otherwise,  they  are  the 
result  of  an  influence  from  within,  the  desire  of  the  university  authori- 
ties to  increase  opportunities  for  investigation  and  to  improve  facilities 
for  teaching.  Both  these  objects  have  been  attained,  and  the  success 
of  many  of  these  laboratories  is  a  most  potent  argument  in  favor  of 
increased  endowment. 

That  such  efforts  are  beginning  to  yield  fruit,  that  the  public  is 
awakening  to  the  importance  of  endowing  research  in  medicine  and  is 
bringing  to  bear  an  influence  from  without,  is  shown  by  the  increasing 
number  of  gifts,  often  spontaneous,  for  the  support  of  investigation 
under  the  control  of  the  university.  Many  of  these  have  been  made 
with  definite  specifications  as  to  the  problems  to  be  studied,  which  is 
encouraging  evidence  of  a  special  study  on  the  part  of  the  donors  and 
of  a  keen  appreciation  on  their  part  of  the  limitations  of  medical 
knowledge  and  of  the  need  of  enlarging  its  boundaries.  Of  depart- 
ments thus  founded,  some  of  the  best  examples  are  those  at  Harvard,^ 
CornelP  and  Columbia^  for  the  study  of  cancer,  the  Henry  Phipps  Insti- 

*  Caroline  Brewer  Croft  Fund  Cancer  Commission. 
^  Collis  P.  Huntington  Fund  for  Cancer  Easearch. 
'George  Crocker  Special  Research  Fund. 


BESEABCH    IN    MEDICINE  81 

tute  and  Hospital,  now  a  part  of  the  University  of  Pennsylvania,  for 
the  study  and  treatment  of  tuberculosis;  the  department  of  experi- 
mental medicine  at  "Western  Reserve;  the  department  of  research  medi- 
cine at  Pennsylvania  for  the  study  of  chronic  diseases,  the  recently 
founded  Sprague  Memorial  Institute  affiliated  with  the  University  of 
Chicago  for  the  study  of  the  general  problems  of  medicine  and  that 
recently  announced  by  Northwestern  University  for  the  study  of  tuber- 
culosis and  other  infectious  diseases.  Here  also  should  be  included  the 
"Wistar  Institute  of  Anatomy  at  Pennsylvania,  the  work  of  which  at 
present  is  devoted  largely  to  research  in  problems  of  the  nervous  system. 
Of  special  interest  in  connection  with  many  of  these  foundations  is 
the  provision  for  investigation  in  the  hospital  in  connection  with  labo- 
ratory work.  Thus  the  foundation  for  the  investigation  of  cancer  at 
Harvard  has  its  own  hospital,  the  Phipps  Institute  at  Philadelphia 
provides  for  the  laboratory  and  clinical  study  of  tuberculosis,  the  new 
Sprague  Institute  of  Chicago  has  a  hospital  affiliation,  the  plans  for 
the  Memorial  Institute  for  Infectious  Diseases  include  a  hospital  for 
the  study  of  such  diseases,  and  some  of  the  smaller  foundations  have 
been  established  with  the  understanding  that  the  university  shall  en- 
sure access  to  the  wards  of  the  hospital  under  its  control.  Surely  the 
universities  through  the  endowment  of  medical  research  will  have  opened 
to  them  invaluable  opportunities  for  service  not  only  in  the  investiga- 
tion of  special  diseases,  but  in  the  broader  field  of  the  relation  of  social 
conditions  to  disease.  In  connection  with  the  latter  Dr.  Richard  C. 
Cabot  has  called  the  attention  of  the  profession  and  hospital  authori- 
ties most  forcibly  to  their  duty  and  to  the  opportunity  for  special  re- 
search which  this  field  offers.  Already  the  Rockefeller  Commission 
for  the  Study  of  Hook-worm  Disease  has  undertaken  the  study  of  social 
conditions  determining  the  occurrence  of  hook-worm  disease  and  the 
University  of  Pennsylvania,  by  establishing,  in  connection  with  the 
Phipps  Institute,  a  department  for  the  sociologic  study  of  tuberculosis, 
offers  the  first  instance  of  a  university  uniting  laboratory,  clinical  and 
sociologic  methods  in  an  effort  to  elucidate  the  problems  of  a  single 
disease.  The  experiment  is  an  important  one  in  that  union  of  effort 
in  the  study  of  a  single  disease,  if  based  on  the  principle  of  social  serv- 
ice as  illustrated  by  the  work  and  writings  of  Cabot,  promises  to  give  to 
university  research  a  new  field  of  activity ;  to  medicine  a  powerful  ally ; 
and  to  society,  an  ideal  of  great  promise  for  the  good  of  the  community. 


82  MEDICAL   BESEABCE   AND    EDUCATION 

To  these  various  influences  which  I  have  presented  at  some  length, 
we  may,  I  believe,  ascribe  what  little  advance  has  been  made  in  univer- 
sity research  in  medicine  in  this  country.  The  same  influences  will 
continue  to  operate.  The  breaking  down  of  the  hard  and  fast  lines 
which  were  drawn  originally  around  the  institutes  of  medicine  will  con- 
tinue. As  in  the  past,  so  in  the  future,  the  formation  of  new  depart- 
ments from  the  older  departments  wiU  limit  the  field  to  be  cultivated 
by  a  single  individual  and  thus  the  time  devoted  to  teaching  a  single 
subject  will  be  divided,  and  as  a  result  more  time  and  opportunity  for 
productive  investigation  will  be  allowed.  Already  immunology  clamors 
to  be  released  from  alliance  with  bacteriology,  hygiene  or  pathology; 
protozoology  claims  a  domain  distinct  from  that  of  bacteriology;  path- 
ological physiology  demands  greater  recognition;  and  a  new  field — ex- 
perimental therapeutics — distinct  from  pharmacology,  is  already  well 
defined;  all  such  expansions  mean  greater  freedom  and  greater  oppor- 
tunit}'  for  investigation.  These  tendencies  and  the  closely  allied  factor, 
the  increased  recognition  of  the  hospital  as  a  place  for  research  (and 
especially  the  planning  of  groups  of  special  hospitals,  as  at  the  Harvard 
Medical  School),  represent  the  forces  within  the  university  which  have 
made  progress  possible.  Of  the  forces  from  without  which  exert  an 
influence,  one,  already  discussed,  is  endowment  for  special  investigation. 
A  second  is  the  influence  exerted  by  independent  institutions  for  re- 
search, as  the  Rockefeller  Institute  and  Hospital,  which  by  its  magnifi- 
cent work  has  stimulated  the  better  university  schools  to  greater  effort 
in  the  advancement  of  medical  knowledge. 

A  third  factor  is  the  demand  of  a  gradually  awakening  public 
opinion  that  medicine  should  take  a  more  prominent  part,  active  and 
advisory,  in  the  affairs  of  the  community.  The  effect  of  this  demand 
is  already  seen  in  the  fact  that  the  limitations  and  aloofness  that  char- 
acterized medicine  in  the  past  have  already  begun  to  disappear,  and  we 
can  confidently  look  forward  to  a  day  when  the  activities  of  medicine, 
on  its  research  and  preventive  sides,  at  least,  will  be — if  I  may  so  ex- 
press it — imbedded  in  the  social  system,  and  shall  live  by  and  for  it. 
In  this  connection,  the  university  should  not  forget  that  the  science  of 
bacteriology  and  the  knowledge  which  it  has  popularized  concerning 
the  etiology  and  control  of  disease  and  pestilence,  formerly  considered 
as  foreordained  and  without  remedy,  has  brought  to  the  race  a  new 
hope  concerning  many  of  man's  afflictions,  and  this  hope  is  tinctured 


BESEASCE    IN    MEDICINE  83 

with  an  impatient  demand  that  all  preventable  diseases,  whether  due  to 
infection  or  occupation,  should  be  thoroughl)''  investigated.  Preventive 
medicine  has  become  a  great  educational  movement,  the  onward  sweep 
of  which  has  been  accelerated  by  modern  views  concerning  the  treat- 
ment of  tuberculosis,  by  municipal  experience  with  the  eflficacy  of  water 
filtration  against  typhoid  fever,  the  "  cleaning  up  "  in  a  hygienic  sense 
of  Havana  during  the  American  occupation,  the  wonderfully  healthy 
state  of  the  Canal  Zone  under  Gorgas  as  compared  with  that  in  the 
time  of  the  French  control,  the  influence  of  a  better  understanding  of 
the  effect  of  hook-worm  disease  on  social  conditions  in  the  south,  and 
the  importance  of  the  destruction  of  the  mosquito  in  the  prevention  of 
yellow  fever  and  malaria.  The  public  looks  first,  and  naturally  so,  to 
its  state  and  municipal  laboratories  for  assistance,  but  it  looks  also  to 
the  laboratories  and  hospitals  of  the  universities  for  that  wise  guidance 
and  direction  which,  untrammeled  by  political  expediency,  is  the  result 
of  impersonal  scientific  observation  and  experiment. 

The  problems  which  may  be  attacked  by  the  university  are  both 
general  and  local;  in  many  instances  a  most  promising  field  of  investi- 
gation lies  at  the  university's  door.  As  is  pointed  out  in  Abraham 
Flexner's  Carnegie  Report  on  Medical  Education,  the  port  of  New 
Orleans  offers  to  Tulane  a  great  opportunity  for  the  study  of  tropical 
diseases,  and  the  industries  of  Pittsburgh  offer  to  its  university  un- 
usual material  for  the  study  of  occupational  diseases.  The  port  of  San 
Francisco,  draining  as  it  does  the  Orient,  and  soon  to  feel  the  influence 
of  the  Panama  canal,  offers  to  the  university  which  will  grasp  it  a  field 
for  the  study  of  tropical  and  unusual  imported  diseases  not  open  to  any 
other  city  in  the  temperate  zone.  Industrial  centers  other  than  Pitts- 
burgh offer  advantages  for  the  study  of  occupational  diseases  and  the 
influence  of  industrial  conditions.  New  York,  Chicago  and  other  large 
cities  with  compact  populations  present  their  own  problems  and  even  in 
sparsely  settled  rural  districts  arise  questions  of  great  importance. 

So  also  every  community  has  the  problems  connected  with  the  dis- 
eases of  infancy  and  of  advancing  j^ears.  The  influence  of  bacteriology 
in  focusing  the  attention  of  investigators  and  of  the  general  public  on 
the  acute  infectious  diseases,  though  an  influence  of  the  greatest  im- 
portance to  medicine  and  one  responsible  for  much  of  the  endowment 
of  research  in  this  country,  has  had  a  tendency,  on  the  other  hand,  to  re- 
tard the  study  of  diseases  not  due  to  bacteria  or  protozoa.    The  pendu- 


84  MEDICAL   BE  SEARCH   AND    EDUCATION 

lum  now,  however,  is  swinging  the  other  way,  and  the  time  has  come  to 
attack,  with  the  aid  of  the  methods  of  chemistry  and  physiology,  the 
chronic  diseases,  the  disturbances  of  metabolism  and  of  internal  secre- 
tion and  the  affections  peculiar  to  infancy  and  old  age.  Only  recently 
have  the  diseases  of  advanced  life  attracted  an  attention  commensurate 
with  their  incidence  and  importance.  As  the  fruits  of  the  investiga- 
tion of  the  acute  infectious  diseases  have  increased  the  expectancy  of 
life  by  diminishing  the  mortality  of  infancy,  childhood  and  early  man- 
hood, so  the  study  of  the  chronic  diseases  incident  to  middle  life  and 
advancing  years,  should,  by  the  determination  of  predisposing  causes 
and  methods  of  prevention,  lead  not  only  to  a  still  greater  stability  of 
life,  but  also,  and  what  is  more  important,  to  a  prolongation  of  years  of 
useful  activity  and,  perhaps,  to  a  serene  instead  of  painful  final  deletion. 

This  leads  to  the  discussion  of  a  new  type  of  department  in  the 
medical  school,  departments  or  chairs  for  research  only.  That  such  de- 
partments are  now  necessary  is  the  direct  result  of  the  unwise  policy 
which,  in  the  past,  has  led  university  presidents  and  medical  faculties 
to  appoint  as  heads  of  departments  men  who  have  little  or  no  training 
as  investigators  and  no  interest  in  research.  As  the  modern  view  of  the 
duties  of  a  medical  school — teaching,  the  first  duty,  but  investigation 
the  corollary,  essential  not  only  for  its  own  sake,  but  also  for  its  influ- 
ence on  teaching — gains  ground,  university  authorities  find  their  chairs 
encumbered  with  men  incapable  and  disinclined  to  conduct  genuine 
university  departments.  New  chairs,  for  research  only,  are  therefore 
established  in  order  to  evade  the  penalty  of  a  wrong  policy  and  at  the 
same  time  to  secure  men  with  the  training  and  ideals  of  the  investi- 
gator. 

When  university  presidents  learn  that  every  professorship,  clinical 
and  otherwise,  ought  to  be  in  some  measure  a  research  chair,  and  that 
research  must  be  combined  with  teaching,  the  need  for  special  depart- 
ments of  research  will  not  be  so  urgent.  It  is  true  that  clinical  teachers 
are  not  united  on  this  point ;  indeed,  the  weight  of  their  opinion  is  often 
thrown  in  the  opposite  direction.  For  example,  the  anti-university 
conception  of  the  university  clinical  professor  has  recently  been  very 
clearly  presented  by  Professor  Barker  in  an  extremely  plausible  argu- 
ment, in  the  course  of  which  he  proposes  that  two  chairs  should  be 
created  in  the  department  of  medicine — one  for  teaching  and  the  finan- 
cial prosperity  of  the  incumbent,  and  the  other  for  research !    No  more 


EESEABCR    IN    MEDICINE  85 

objectionable  proposition  from  a  university  point  of  view  has  ever  been 
made.  Officially  recognized  and  sanctioned  separation  of  research  from 
teaching,  especially  in  the  clinical  chairs,  would  not  only  place  the  uni- 
versity on  the  level  of  the  secondary  school,  but  would  delay  all  progress 
in  medicine,  and,  more  important  still,  destroy  what  little  confidence 
the  public  is  beginning  to  have  in  the  altruism  of  university  medical 
education.  Let  us  hope  that  such  counsels  may  not  prevail.  Let  us 
work  for  the  recognition  of  the  principle  that  teaching  and  research 
should  be  combined  in  every  department  of  the  medical  school.  In  the 
meantime,  special  departments  of  research  may  well  be  created,  not 
only  to  make  up  for  the  sterility  of  the  other  chairs,  but  in  order  to  at- 
tack problems  that  are  of  such  magnitude  and  complexity  that  they 
may  well  engage  the  entire  time  of  those  devoted  to  them.  But  neither 
research  professorships  nor  research  institutes  can  ever  relieve  the  pro- 
fessor of  medicine  or  of  surgery  from  the  duty  and  obligation  to  con- 
tinue to  be  creatively  occupied  in  the  development  of  their  respective 
departments. 

Existing  departments  of  research  are  variously  described  as  de- 
partments of  experimental  pathology,  experimental  medicine  or  research 
medicine.  The  title  matters  little,  but  the  plan  of  the  department 
should  be  broad  enough  to  care  for  the  problems  of  clinical  medicine,, 
and  for  this  reason  the  word  "medicine"  should  appear  in  the  title 
rather  than  the  word  "pathology."  Such  a  department  should  keep 
in  close  touch  with  the  department  of  clinical  medicine,  should  supple- 
ment the  facilities  of  the  various  hospital  laboratories,  and  should  also 
work  in  cooperation  with  the  fundamental  laboratory  sciences  in 
order  to  insure  no  loss  of  opportunity  in  the  prosecution  of  its  prob- 
lems and  thus  a  realization  of  the  greatest  good  to  the  school.  The 
head  of  the  department  should  be  a  man  familiar  with  the  problems  of 
clinical  medicine,  trained  preferably  as  a  pathologist,  and  with  suffi- 
cient knowledge  of  the  possibilities  of  physiology  and  chemistry  to  apply 
the  methods  of  these  subjects  to  clinical  problems.  I  say  preferably  a 
pathologist  because  the  pathologist  is  more  apt  to  combine  clinical 
training  with  a  knowledge  of  pathology,  bacteriology  and  the  prin- 
ciples of  immunity  than  is  the  physiologist,  chemist  or  pharmacologist, 
though  any  one  of  the  latter  might  well  head  such  a  department.  Cer- 
tain it  is  that  whatever  his  own  training  may  have  been,  the  director 
should,  with  his  assistants,  be  able  to  utilize  in  the  work  of  the  depart- 


86  MEDICAL   BESEABCH   AND    EDUCATION 

ment  the  methods  of  physiology,  chemistry,  bacteriology  and  experi- 
mental pathology.  In  other  words,  he  should  have  a  department  capable 
of  attacking  a  problem  in  medicine  from  any  or  all  sides,  including 
that  of  experimental  therapeutics;  and  in  order  to  make  the  work 
effective,  he  should  have  the  use  of  beds  in  the  university  hospital. 

The  work  of  this  department  should  be  the  investigation  of  clinical 
problems,  and  not  of  academic  problems  of  pathology,  chemistry  or 
physiology.  General  practitioners,  clinical  assistants  in  the  school  and 
even  those  at  the  head  of  clinical  departments  are  constantly  meeting 
problems  which  demand  solution,  but  find  no  adequate  opportunity  to 
investigate  them  in  departments  as  now  constituted.  These  men  would 
find  a  place  in  the  department  suggested  and  should  constitute  an  en- 
thusiastic working  staff  which  should  be  exceedingly  productive  in  the 
advance  of  medical  knowledge. 

I  may  be  over-enthusiastic  about  this  matter,  but  I  believe  that 
departments  such  as  I  have  outlined  are  a  necessary  part  of  every  large 
university  medical  school,  and  must  be  developed  eventually  through 
the  combined  efforts  of  the  pathologist  and  the  clinician,  who  have 
naturally  a  greater  interest  in  the  problems  of  disease  than  have  the 
men  of  other  departments  and  who  must  have  a  research  department 
devoted  to  their  common  interests. 

A  department  of  this  type,  whether  independent  or  affiliated  with 
the  chair  of  medicine,  I  would  recommend  to  every  university  which 
sees  its  way  to  procure  endowment  for  research  in  medicine,  for  in  a 
department  of  such  broad  scope  lies  the  possibility  of  attacking  many 
problems  in  the  broadest  way  and  of  assuring  the  best  utilization  of 
endowment  and  the  greatest  good  for  the  greatest  number. 

This  discussion  might  be  lengthened  by  the  presentation  of  other 
phases  of  the  subject  of  medical  research,  but  I  may  well  end  with  Mr. 
Eliot's  all-inclusive  characterization: 

Medical  research  habitually  strives  to  arrive  at  something  beyond  abstract 
truth.  It  seeks  to  promote  public  and  private  safety  and  happiness,  and  the 
material  welfare  of  society.  Its  devotees  have  in  mind  the  discovery  of  means  of 
remedying  misery  or  warding  off  calamity;  and  they  know  that  whatever  con- 
tributes to  health  or  longevity  in  any  community  or  nation  contributes  to  its 
industrial  prosperity;  so  that  they  are  justified  in  hoping  for  results  from  their 
work  which  will  promote  human  welfare. 

If  my  presentation  of  the  subject  of  research  in  medicine,  which  now 
comes  to  its  close,  has  any  value  it  lies  in  an  attempt  to  demonstrate 


BE  SEARCH    IN    MEDICINE  87 

two  things:  (1)  That,  wonderful  as  were  the  isolated  achievements  of 
the  great  discoverers  in  medicine  in  the  early  centuries,  the  great  con- 
tinuous advance  in  medicine  during  the  past  eighty  years  resulted  from 
organized  laboratory  effort  based  on  the  principle  of  exact  experimental 
methods,  and  (2)  that  it  is  the  duty  of  the  university  so  to  organize  its 
laboratories  and  hospital  that  this  advance  of  medicine  by  research- may 
continue,  side  by  side  with  teaching,  as  a  university  function  of  benefit 
to  student  and  facult}',  as  well  as  to  the  state  and  the  general  public 
welfare,  and  thus  as  an  aid  to  the  advancement  of  civilization. 

BIBLIOGRAPHY 

The  many  and  varied  sources  of  the  material  presented  in  these  lectures  it 
would  be  difficult  to  set  down.  The  following  list  represents  the  more  important 
books,  addresses  and  other  publications  used  as  constant  guides  in  the  epitomiza- 
tion  of  various  eras,  or  for  the  purpose  of  direct  or  indirect  quotation. 

Books 

Cabot,  E.  C.  Social  Service  and  the  Art  of  Healing. 
Cambridge  Modern  History,  The.  Vols.  X.  and  XII. 
Dabmstaedter,  L.,  and  Du  Bois-Eeymond,  E.     4,000  Jahre  Pionier — Arbeit  in' 

den  exakten  Wissenschaften. 
Draper,  J.  "W.     History  of  the  Conflict  between  Eeligion  and  Science. 
Flexner,  a.     Medical  Education  in  the  United  States — Bulletin  No.  4  of  the 

Carnegie  Foundation  for  the  Advancement  of  Teaching. 
Foster,  M.    Masters  of  Medicine — Claude  Bernard. 
Gorton,  D.  A.     The  History  of  Medicine. 
Harrison,  F.     The  Meaning  of  History. 
Herter,  C.  a.     The  Influence  of  Pasteur  on  Medical  Science. 
Lawrence,  E.  M.     Primitive  Psycho-Therapy  and  Quackery. 
MacFie,  E.  C.     The  Eomanee  of  Medicine. 

Merz,  J.  T.     History  of  European  Thought  in  the  I^Tineteenth  Century. 
MUMFORD,  J.  G.     Surgical  Memoirs. 
MUMFORD,  J.  G.     A  Narrative  of  Medicine  in  America. 
Neuberger,  M.     History  of  Medicine. 
Park,  E.    An  Epitome  of  the  History  of  Medicine. 
EussEL,  J.  E.     The  History  and  Heroes  of  the  Art  of  Medicine. 
Stirling,  "W.     Some  Apostles  of  Physiology. 
Traill,  H.  D.     Social  England. 
Vallery-Eadot,  E.     The  Life  of  Pasteur. 
Williams,  H.  S.     A  History  of  Science. 

Encyclopedia  Britannica — 11th  Edition 

Allbutt,  T.  C.     History  of  Medicine. 
Payne,  J.  F.     History  of  Medicine.  ' 


88  MEDICAL   BESEABCE    AND    EDUCATION 

Al>DEESSES   AND   PAPEBS 

Allen,  F,     The  Twofold  Function  of  the  University,  Science,  1910,  XXXII.,  901. 
Barker,  L.  F.     Medicine  and  the  Universities,  Amer.  Med.,  1902,  IV.,  143. 
Barker,  L.  F.     Medical  Laboratories;   Their  Eelation  to  Medical  Practice  and 

to  Medical  Discovery.     Science,  1908,  XXVIL,  601. 
Barker,  L.  F.     Some  Tendencies  in  Medical  Education  in  the  United  States, 

Jour.  Am.  Med.  Assoc,  1911,  LVIL,  613. 
Buchheim,  R,     Ueber  die  Aufgaben  und  die  Stellung  der  Pharmacologie  an  den 

deutschen  Hochschulen.    Arch.  f.  Exper.  Path,  u.  Pharmak.,  1876,  V.,  261. 
Cabot,  R.  C.     Ethical  Forces  in  the  Practice  of  Medicine.     (An  address  delivered 

before  the  students  of  Harvard  University,  on  April  13,  1905.) 
Cabot,  R.  C.     On  the  Relation  between  Laboratory  Work  and  Clinical  Work, 

Boston  Medical  and  Surgical  Journal,  1911,  CLXIV.,  880. 
Calkins,  G.     The  Scope  of  Protozoology,  Science,  1911,  XXXIV.,  129. 
Councilman,  W.  T.     The  Relation  of  Pathology  to  Medicine,  Trans.  Mass.  Med. 

Society,  1898. 
Eliot,  C.  W.     Address  at  the  Formal  Opening  of  the  Laboratories  of  the  Rocke- 
feller Institute  for  Medical  Research,  Science,  1906,  XXIV.,  13. 
jACOBi,  A.     An  address  before  the  Medical  School  of  McGill  University,  New 

Yorlc  Medical  Journal,  1905,  LXXXII.,  729. 
Keen,  W.  W.     The  Debt  of  the  Public  to  the  Medical  Profession,  Phila.  Med. 

Journal,  1899,  III.,  939. 
Marks,  L.  H.     Ehrlich  's  Biochemical  Therapy,  Its  Conception  and  Application, 

Jour^  Amer.  Med.  Assoc,  1910,  LV.,  1974. 
Minot,  C.  S.     The  Relation  of  Embryology  to  Medical  Progress,  The  Popular 

Science  Monthly,  1906,  July. 
Park,  W.  H.     A  Critical  Study  of  the  Results  of  Serum-Therapy  in  the  Disease 

of  Man,  Harvey  Lecture,  1906. 
Pearce,  R.  M.     The  Experimental  Method;    Its  Influence  on  the  Teaching  of 

Medicine,  Jour.  Am.  Med.  Assoc,  1911,  LVIL,  1017. 
Schweitzer,    H.     Ehrlich 's    Chemotherapy — A    New    Science,    Science,    1910, 

XXXIL,  809. 
Sedgwick,  W.  T.     The  Relations  of  Public  Health  Science  to  Other  Sciences, 

American  Medicine,  1905,  IX.,  975. 
Vincent,    G.   E.     The   Purpose   and   Spirit   of   the    University,    Science,    1911, 

XXXIIL,  977. 
Welch,  W.  H.     The  Endowment  of  Research,  Science,  1906,  XXIV.,  6. 
Welch,  W.  H.     The  Relation  of  the  Hospital  to  Medical  Education  and  Re- 
search, Jour.  Amer.  Med.  Assoc,  1907,  XLIX.,  531. 
Welch,  W.  H.     The  Interdependence  of  Medicine  and  Other  Sciences  of  Nature, 

Science,  1908,  XXVIL,  49. 
Welch,  W.  H.     The  Evolution  of  Modern  Scientific  Laboratories,  Johns  HopJcins 

Hospital  Bulletin,  1896,  VII.,  19. 


THE  EXPEEIMENTAL  METHOD :  ITS  INFLUENCE  ON  THE 

TEACHING  OF  MEDICINE^ 

By  Eiciiard  M.  Pearce,  M.D., 
Professor  of  Eesearch  Medicine,  University  op  Pennsylvania 

When  I  was  invited  to  address  this  society  and  it  was  suggested 
that  I  take  as  my  subject  the  methods  of  experimental  medicine,  I  ex- 
perienced more  than  the  usual  pleasure  afforded  by  such  an  invitation, 
for  it  offered  me  not  only  a  rare  privilege,  that  of  addressing  in  a 
formal  manner  the  student  body  of  the  school  in  which  I  once  labored 
as  student  and  instructor,  but  also  the  opportunity  of  acknowledging 
my  indebtedness  to  various  members  of  your  faculty,  past  and  present, 
who  by  their  methods  of  instruction  gave  me  my  first  insight  into  those 
experimental  methods  and  scientific  procedures  on  which  all  that  is  of 
value  in  medicine  is  based.  For  example,  my  first  lesson  in  exact  ob- 
servation was  given  me  by  Dr.  Minot  in  one  of  my  earlier  exercises  in 
histology.  I  was,  as  were  at  that  time  many  students  of  this  school, 
poorly  prepared  in  the  experimental  methods,  but  well  versed  in  the 
methods  of  using  a  text-book.  I  thought  I  knew  from  my  reading  the 
essential  details  of  the  structure  of  a  cell,  and  accordingly  prepared 
with  ease  and  rapidity  what  I  considered  to  be  excellent  pencil  sketches 
of  the  material  offered  in  the  first  few  days  of  the  course.  I  remember 
well  my  incredulity  and  then  my  amazement  and  chagrin  when  Dr. 
Minot  demonstrated  to  me  that  I  had  not  drawn  the  cells  I  thought 
I  saw  under  the  microscope,  but  the  cells  visualized  from  the  text- 
books. Even  to  this  day  I  do  not  see  a  frog  without  calling  up  that 
picture  of  the  frog's  epidermis,  of  Dr.  Minot  and  of  my  first  lesson  in 
exact  observation;  a  lesson  which  it  may  please  Dr.  Minot  to  know  I 
consider  the  most  valuable  single  lesson  of  my  experience.  I  can  re- 
member nothing  else  about  that  course  in  histology,  but  that  one  lesson 
I  have  never  forgotten.  This  training  was  continued  by  others,  but 
particularly  by  Dr.  Councilman  and  Dr.  Mallory,  not  only  when  as  a 

^  An  address  given  under  the  auspices  of  the  Alpha  Omega  Alpha  Honorary 
Medical  Fraternity,  Harvard  University.  Published  in  the  Journal  of  the  Amer- 
ican Medical  Association,  1911. 

89 


90  MEDICAL   BESEAECH   AND   EDUCATION 

student  I  received  my  instruction  in  pathology,  but  also  during  several 
delightful  years  as  assistant  in  the  Department  of  Pathology.  To 
these  and  other  members  of  this  faculty,  past  and  present,  I  owe  my 
early  instruction  in  the  methods  of  scientific  investigation  and  much  of 
stimulus  and  encouragement,  and  to  you,  for  the  opportunity  you  have 
given  me  of  expressing  this  appreciation  of  my  debt,  I  am  sincerely 
grateful. 

The  phase  of  experimental  medicine  which  I  am  about  to  discuss 
is  not,  perhaps,  that  which  your  secretary  had  in  mind  when  he  sug- 
gested as  a  subject  "Experimental  Medicine;  its  methods,  what  it  has 
accomplished;  the  problems  before  it;  and  what  it  may  hope  to  do  in 
the  future."  These  specifications  might  easily  have  been  fulfilled  by  a 
compilation  of  the  achievements  and  accomplishments  of  scientific 
medicine,  detailed  in  historical  sequence  or  grouped  about  the  activities 
or  methods  of  some  particular  field  of  endeavor.  Of  late,  however,  so 
much  has  been  written  along  these  lines  that  I  fear  such  a  presentation 
might  have  a  familiar,  laudatory  tone,  and  leave  you  with  a  feeling  of 
too  great  complacency  concerning  the  progress  of  our  science.  I  in- 
tend, therefore,  while  still  adhering  to  the  formula  set  me,  to  neglect 
the  triumphs  of  the  investigator  and  to  point  out,  at  the  risk  of  being 
misunderstood,  the  importance  of  the  experimental  method  in  the 
every-day  work  of  the  student  and  the  teacher  of  medicine ;  and  how,  if 
conscientiously  applied,  it  may  thus  exert  a  powerful  influence  in  the 
development  of  the  science  of  clinical  medicine. 

First,  a  word  may  be  said  about  the  experimental  or  scientific 
method.  According  to  Minot  it  is  "  the  right  method  of  ascertaining 
the  objective  truth"  and  differs  from  our  every-day  methods  only  in  its 
precision ;  according  to  Von  Baer  it  is  "  observation  and  reflection  " ; 
Huxley  characterizes  it  as  "  nothing  but  trained  and  organized  common 
sense."  It  is  the  sentiment  expressed  in  Sir  Astley  Cooper's  "  First  ob- 
serve and  then  think."  I  doubt  not  that  these  expressions  are  familiar 
to  you  all,  that  you  are  accustomed  to  the  procedures  they  describe,  and 
have  benefited  by  their  application  in  the  hands  of  your  instructors. 
If  so  you  are  more  fortunate  than  the  great  bulk  of  medical  students; 
for  it  is  my  profound  conviction  that  the  greatest  fault  in  our  medical 
teaching  is  the  failure  of  the  majority  of  teachers  to  practise,  when  in 
actual  contact  with  the  students,  those  scientific  methods  which  they 
recommend  in  theory,  and  which  some  of  them  vigorously  apply  in 


TRE   EXPEEIMENTAL   METHOD  91 

their  own  investigations.  This  is  a  sweeping  statement,  but  it  is  based 
on  my  personal  experience  as  a  teacher  in  nearly  half  a  dozen  schools 
and  on  an  intimate  knowledge  of  the  methods  of  instruction  and  of  the 
men  giving  the  instruction  in  at  least  a  dozen  more;  and,  moreover,  it 
is  made  with  a  full  appreciation  of  the  wonderful  advance  in  labora- 
tory instruction  in  all  branches  of  medicine  during  the  past  fifteen 
years.  My  statement,  I  realize,  must  be  supported,  and  as  my  proof 
must  be  more  or  less  in  the  nature  of  criticism,  the  task  I  have  set 
myself  is  not  a  pleasant  one.  In  fact,  I  w^ould  not  have  entered  into 
this  discussion  if  it  were  not  that  our  product,  our  graduate  in  medi- 
cine, has  been  found  wanting  by  the  German  finishing  school.  Pro- 
fessor Graham  Lusk,  than  whom  there  is  no  more  fearless  champion  of 
scientific  idealism,  stated  in  a  recent  address  that  a  friend  was  told  by 
a  prominent  professor  of  medicine  in  a  German  university  that  the 
greater  number  of  young  Americans  who  came  there  to  study  were  "  no 
good."  Twenty-five  years  ago  such  a  statement  would  not  have  been 
surprising,  but  now,  with  our  much-vaunted  laboratory  methods  and 
our  improved  clinical  teaching,  the  statement  is,  to  say  the  least,  dis- 
comfiting. The  "  greater  number  "  of  American  students  going  abroad 
may  be  from  the  poorer  schools,  and  if  so,  which  hardly  seems  prob- 
able, the  criticism  is  unjust  to  our  schools  of  the  better  type.  If,  how- 
ever, it  represents  the  true  condition,  from  the  German  point  of  view, 
then,  as  Lusk  puts  it,  "  our  educational  system  is  at  fault.  It  can  not 
be  that  American  intellect  is  inferior.  The  trouble  lies  in  our  system." 
It  is  these  statements  which  have  crystallized  my  own  misgivings 
as  to  the  shortcomings  of  our  methods  of  instruction.  These  short- 
comings may  occur  in  the  laboratory  work  of  the  first  two  years  or  in 
the  clinical  work  of  the  third  and  fourth  years,  but  the  teachers  in  the 
laboratory  years  are  responsible  for  the  point  of  view  with  which  the 
student  approaches  the  material  of  the  clinician,  and  they  should  con- 
sider it  not  only  a  duty,  but  a  privilege  and  an  opportunity  of  the  gi'eat- 
est  moment,  to  train  the  student  in  method  and  in  accuracy  of  obser- 
vation. If  the  teachers  of  the  first  and  second  years  do  their  duty  in 
this  regard  the  student  himself  will  demand  and  obtain  better  teach- 
ing the  third  and  fourth  years.  Do  the  heads  of  our  laboratory 
departments  always  grasp  this  opportunity?  Is  this  opportunity 
grasped  by  the  man  who  sees  his  class  only  as  it  is  seated  in  the 
amphitheater,  who  lectures  four  or  five  times  a  week  and  never  or 


92  MEDICAL   EESEABCH    AND    EDUCATION 

hardly  ever  goes  into  the  laboratory  where  his  students  are  at  work? 
And  what  shall  we  say  about  the  man  who  reads  his  lectures,  the 
students  acting  the  part  of  eflEicient  stenographers,  fearful  of  miss- 
ing a  word,  because,  without  emphasis  of  important  points,  they  must 
get  every  word  for  the  necessary  and  inevitable  cram  ?  And  then,  most 
ludicrous  of  all,  the  man  who  lectures  from  his  own  text-book,  his  audi- 
tors not  taking  notes  but  underlining  the  text  of  the  same  book? 
There  must  be  something  of  peculiar  dignity  in  the  professorial  utter- 
ance, which  I  must  admit  I  have  never  appreciated,  to  allow  the  per- 
petuation of  this  method.  Better  that  such  teachers  should  sell  their 
dignity  in  the  form  of  text-books  or  printed  notes,  at  a  profit,  than  that 
they  should  waste  their  own  time,  as  well  as  that  of  the  men  they  thus 
vainly  attempt  to  teach.  One  of  your  faculty  writes  thus  of  the  lec- 
ture :  "  The  very  best  that  can  be  said  of  a  lecture  or  a  book  is  that  it 
describes  well  the  knowledge  which  some  one  possesses.  A  book  or  lec- 
ture can  serve  only  to  assist  a  man  to  acquire  knowledge  with  lessened 
loss  of  time.  Knowledge  lives  in  the  laboratory;  when  it  is  dead,  we 
bury  it  decently  in  a  book"  (Minot).  One  may  add  that  a  lecture  on 
knowledge  thus  decently  buried  in  a  book  is  itself  deadly  in  its  influence 
on  the  student. 

Complete,  voluminous,  detailed  lectures  may  have  been  necessary  in 
the  days  of  poorly  prepared  students,  but  with  our  present  require- 
ments in  physics,  chemistry,  biology  and  the  languages  they  are  un- 
necessary. The  department  head  who  inaugurates  his  week's  work  with 
a  general  summary  of  the  character  of  the  laboratory  exercises  of  that 
period,  emphasizes  the  important  phases  of  the  subject  and  suggests  the 
matter  to  be  read,  can  leave  the  details  which  take  the  time  of  the  sec- 
ond, third,  fourth  and  fifth  lectures  to  the  student  himself  and  to 
amplification  in  the  laboratory.  Or,  if  this  does  not  suffice  in  his  mind 
to  present  the  subject-matter  properly,  a  second  hour  with  the  lantern 
is  worth  half  a  dozen  formal  lectures.  At  the  end  of  the  week,  after 
the  laboratory  work  is  completed,  a  third  hour,  for  a  conference  recita- 
tation,  which  he  conducts  personally,  should  clear  up  all  doubtful 
points.  Ib.  this  recitation  the  men  should  not  be  marked ;  it  should  be 
an  informal  affair,  with  the  sole  object  of  determining  the  efficiency  of 
the  week's  instruction  and  of  the  progress  in  the  power  of  observation 
and  deduction.  Such  a  method  alwavs  succeeds.  I  have  tried  it  for 
three  years,  in  two  different  schools,  always  supplementing  it  by  per- 


THE    EXPERIMENTAL   METHOD  93 

sonal  attendance  in  the  students'  laboratory,  and  my  experience  is  such 
that  I  usually  apologize  for  the  occasional  extra  lecture  now  and  then 
apparently  necessary. 

A  student  of  medicine  in  iSTew  York  City,  in  1906,  presented  in  the 
correspondence  columns  of  one  of  our  medical  journals  a  very  accurate 
picture  of  the  evils  of  the  lecture  system.  Eeferring  to  the  good,  aver- 
age student,  he  says:  "Such  a  student  goes  to  the  (medical)  school 
anxious  to  learn.  Five  to  one  he  does  not  know  how  to  learn;  ten  to 
one  he  does  not  know  how  to  think !  During  the  first  two  years  he  has 
forced  on  him  such  a  cold  douche  of  slippery  facts  that  his  warm  young 
enthusiasm  is  chilled  to  the  marrow."  I  think  most  students  who  are 
freely  lectured  to  will  agree  with  this  critic.  Complete  presentation  of 
a  subject  in  a  lecture,  even  though  the  facts  be  retained,  stifles  curiosity 
and  inquiry,  turns  the  interest  of  the  student  backward  instead  of 
forward,  and  retards  the  development  of  that  scientific  method  of 
thought  so  satisfying  as  a  part  of  one's  mental  equipment.  Complete 
and  voluminous  lectures,  which  discourage  collateral  reading  and  mini- 
mize individual  laboratory  work,  force  the  student  to  consider  the  final 
examination  to  be  the  ultimate  object  of  the  course.  In  some  schools 
the  student  is  encouraged  in  this  point  of  view  by  the  establishment, 
often  with  the  consent  and  approval  of  the  head  of  the  department,  of 
extramural  quizes,  which,  given  by  assistants  of  the  department,  in- 
crease the  income  of  the  latter  at  the  expense  of  the  student's  mental 
development.  This  system  can  not  be  too  severely  condemned,  and  it  is 
a  favorable  omen  that  we  find  it  no  longer  countenanced  by  conscien- 
tious teachers  trained  in  modern  methods.  The  latter  discourage  vol- 
uminous note-taking  and  advise  the  student  to  take  merely  an  outline 
of  the  lecture  and  then  to  supplement  this  by  independent  reading  and 
by  personal  observation  in  the  laboratory.  This  places  the  student  in 
the  position  of  an  investigator  who  reaches  his  conclusions  more  or  less 
independently  and  thus  gains  both  in  method  and  in  power.  Errors  in 
interpretation  can  always  be  corrected  by  a  weekly  conference-recita- 
tion held  by  the  head  of  the  department,  and  this  method  has  in  my 
experience  been  so  highly  esteemed  by  the  student  body  as  not  only  to 
kill  the  extramural  quiz,  but  also  to  increase  greatly  the  capacity  of  the 
student  for  independent  work. 

Another  fault  of  the  lecture  system  is  the  not  infrequent  arrange- 
ment which  allows  the  head  of  the  department  to  consider  lecturing 


94  MEDICAL   BE  SEARCH   AND   EDUCATION 

his  only  duty  and  permits  him  to  turn  over  the  laboratory  work  to  as- 
sistants. If  the  laboratory  instruction  is  to  be  not  merely  a  matter  of 
perfunctory  routine,  but  is  to  be  used  for  training  in  the  experimental 
method  with  the  object  of  developing  power  in  method  and  in  observa- 
tion, it  becomes  one  of  the  most  difficult  forms  of  teaching,  and  no 
matter  how  adequately  trained  the  assistants  may  be,  the  daily  pres- 
ence of  the  head  of  the  department,  if  he  have  the  proper  point  of  view, 
is  essential  to  the  success  of  the  laboratory  instruction.  Some  of  our 
teachers  in  anatomy  and  pathology  have  been  so  impressed  by  the  ad- 
vantages of  this  system  as  to  abandon  all  formal  lectures.  If  I  were 
forced  to  a  choice  I  would  cling  to  the  privilege  of  teaching  in  the  lab- 
oratory and  turn  over  the  lectures  to  my  assistants. 

I  am  not,  however,  one  of  those  who  believe  in  abolishing  the 
didactic  lecture.  Combined  with  demonstrations  and  laboratory  work 
it  is  of  great  value,  in  the  proportion  of  about  one  hour  of  lecture  to 
six  or  eight  hours  of  actual  laboratory  or  clinical  work  by  the  student, 
but  the  manner  in  which  it  is  overworked  in  some  branches,  as  anatomy, 
a  subject  which  has  its  laboratory  material  always  at  hand  and  in 
abundance  ^and  is  not  handicapped  by  the  absence  of  excellent  text- 
books, leads  one  to  believe  that  the  lecture  thrives  merely  because  it  is 
from  the  instructor's  point  of  view  the  easiest  method  of  teaching. 
On  the  other  hand,  in  some  subjects,  as  physiologic  chemistry,  pharma- 
cology and  immunology,  in  which  advances  are  being  rapidly  made  and 
which  for  this  reason  have  no  adequate  text-books,  frequent  and  com- 
plete lectures  are  necessary. 

Let  us  now  turn  to  the  instruction  in  the  laboratory  itself,  where 
we  should  certainly  expect  to  find  experimental  methods  conscientiously 
practised.  We  have  every  reason  to  be  proud  of  the  equipment  and 
facilities  of  most  of  the  laboratories  in  our  better  medical  schools. 
In  no  country  has  the  idea  of  laboratory  instruction  so  rapidly  advanced 
as  in  America.  Visitors  from  European  schools  express  amazement  at 
our  complete  outfits  for  the  individual  student.  Expensive  as  such 
outfitting  has  been,  university  trustees  have  met  the  demand  willingly 
and  their  attitude  in  this  respect  has  been  one  of  the  most  pleasing 
phases  of  the  recently  awakened  interest  in  proper  education  in  medi- 
cine. Thirty  instit^^tions,  according  to  the  recent  Carnegie  Eeport  on 
Medical  Education,  have  well-equipped  laboratories  to  teach  the  medical 
sciences.     With  the  other  hundred-odd  schools  we  are  not  concerned. 


THE    EXPEEIMENTAL    METHOD  95 

for  these,  if  they  do  not  establish  proper  laboratories,  must  cease  to 
continue  as  factors  in  medical  education.  And  of  the  thirty  my 
remarks,  I  may  say,  refer  only  to  the  best,  to  those  which  are  ambitious 
to  properly  present  the  scientific  side  of  medicine  in  a  really  scientific 
manner.  Do  the  teachers  of  our  best  schools  always  keep  in  mind  that 
their  chief  function  is  the  training  of  the  physician  and  that  for 
this  purpose  the  constant  application  of  the  experimental  method  is 
essential  ? 

The  guiding  principle  of  laboratory  instruction  should  be  the  prac- 
tise of  the  "  do  it  yourself "  idea.  Lectures,  amphitheater  demon- 
strations and  recitations  should,  if  time  can  not  otherwise  be  obtained, 
give  way  to  actual  individual  work  in  the  laboratory.  Furthermore, 
the  department  head,  without  sacrificing  the  presentation  of  his  subject 
as  a  training  in  method,  should  prominently  place  before  the  student 
its  relation  to  other  courses  in  the  medical  curriculum,  and  especially 
to  the  clinical  work  which  is  to  follow.  This  latter  view  is,  I  know, 
opposed  by  some  of  our  most  prominent  teachers  of  physiology  and 
chemistr}'',  but  as  the  first  object  of  a  medical  school  is  to  train  physi- 
cians, we  must  teach  applied  science  as  well  as  pure  science. 

Nearly  all  our  laboratory  courses  offer  opportunity  for  criticism 
from  these  two  points  of  view.  Anatomy,  aside  from  the  error  of 
overlecturing,  is  perhaps  least  at  fault,  for  abundant  material  for  dis- 
section makes  this  course,  if  the  material  is  properly  utilized,  an  ideal 
one  for  the  practise  of  the  "  do  it  yourself "  method.  The  related 
subjects,  histology  and  embryology,  may,  however,  be  criticized  in  that 
they  are  seldom  taught  in  relation  to  one  another  or  to  gross  anatomy, 
and  practically  never  with  a  regard  to  the  work  in  physiology  and 
pathology  which  follows.  Of  the  few  exceptions,  Huberts  course  at 
Michigan  best  illustrates  how  these  subjects  should  be  presented. 
Embryology  forms  the  basis  of  the  work  in  histology;  the  student 
studies  cell  division  and  the  development  of  the  germ  layers,  and  as 
the  tissues  and  organs  are  differentiated  the  histology  of  each  is  studied 
in  adult  tissues.  Thus  the  structure  of  each  adult  tissue  and  organ  is 
brought  into  relation,  on  the  one  hand,  with  its  origin  and  its  order  of 
development,  and,  on  the  other,  by  judicious  correlative  teaching,  with 
important  basic  principles  of  pathology;  as,  for  example,  the  general 
laws  concerning  the  origin  of  tumors,  or  the  similarity  of  the  repair  or 
regeneration  of  an  adult  tissue  to  the  embryonic  development  of  the 


96  MEDICAL   BESEAECH   AND   EDUCATION 

same  tissue,  or  the  developmental  explanation  of  the  anatomy  of  hernia. 
These  and  other  important  fundamental  principles  can  be  taught  better 
by  the  embryologist  than  by  the  pathologist. 

Another  neglected  field  is  that  on  the  border-line  between  histology 
and  gross  anatomy,  which  for  the  want  of  a  better  name  may  be  called 
"  semi-gross  "  anatomy.  The  well-trained  student  can  from  memory 
give  a  fairly  accurate  description  of  the  relations  and  gross  external 
appearance  of  an  organ  and  also  of  its  histologic  structure,  but  he  is  at 
sea  when  asked  to  point  out  on  the  freshly  cut  surface  of  an  organ  its 
normal  markings.  The  appearance  of  the  Malpighian  bodies  of  the 
spleen,  of  the  glomeruli  of  the  kidney,  the  differentiation  of  arteries 
or  veins  from  the  bronchi  in  the  lung  or  from  the  bile-ducts  in  the  liver 
are  matters  of  which  he  knows  nothing.  His  theoretical  knowledge 
fails  when  put  to  the  practical  test.  This  is  due  entirely  to  the  fact 
that  the  gap  between  the  experience  of  the  dissecting  room  and  that  of 
the  histologic  laboratory  is  hardly  ever  filled,  as  it  should  be,  by  the 
study  of  fresh  organs  in  the  latter  course.  Properly  to  correlate  the 
teaching  of  embryology,  histology  and  anatomy  is  one  of  the  most 
important  duties  of  the  department  of  anatomy. 

It  is,  however,  of  the  work  in  physiology,  pathology,  bacteriology 
and  pharmacology  that  I  wish  especially  to  speak.  The  first  and  second 
of  these  sciences  are  concerned  essentially  with  normal  and  abnormal 
functions,  the  third  with  one  phase  of  the  etiology  of  altered  function 
and  the  fourth  with  the  treatment  of  abnormal  function.  They  there- 
fore lend  themselves  to  teaching  from  the  dynamic  rather  than  from 
the  static  or  descriptive  point  of  view,  and  are  peculiarly  adapted  to 
the  procedures  of  the  experimental  method.  These  are  subjects  which 
offer  the  possibility  of  bringing  the  student  closer  to  an  understanding 
of  the  manifestations  of  disease,  and  the  factors  which  cause  and  influ- 
ence these  manifestations,  than  any  other  group  of  subjects  in  the 
medical  curriculum.  Physiology  and  pathology  should  be  so  taught 
as  to  force  the  student  and  physician  to  think  physiologically  and  not 
morphologically,  as  is  usually  the  case.  The  close  adherence  of  both 
of  these  sciences  to  the  descriptive  method  may  be  explained  historically 
in  the  case  of  physiology  by  the  development  of  physiology  by  anat- 
omists, physicists  and  chemists  rather  than  by  biologists  in  the  broad 
sense.  The  influence  of  the  descriptive  anatomist  is  seen  in  the  early 
association  of  histology  with  physiology;  of  the  physicist  in  the  early 


THE    EXPEBIMENTAL    METHOD  97 

electrophysiology,  and  of  the  chemist  in  the  early  analytical  trend  of 
physiologic  chemistry.  Likewise,  pathology,  adopting  the  methods  of 
anatomy,  became  a  purely  descriptive  science,  seeking  the  seat  of  disease 
and  concerned  with  the  appearance  of  diseased  tissues.  I  have  no 
desire  to  minimize  the  importance  of  this  anatomic  conception,  for  it 
has  been,  under  the  stimulus  of  Virchow's  genius,  one  of  the  most 
important  principles  in  the  history  of  medicine  and  most  fruitful  as  a 
guide  to  investigation.  But  Virchow's  conception  was  not  narrow  and 
his  writings  continually  reveal,  as  does  also  the  title  of  his  Archives, 
his  appreciation  of  the  importance  of  physiologic  and  other  experi- 
mental methods  in  the  study  of  pathology.  Such  methods,  however, 
were  seldom  applied,  and,  with  the  exception  of  Cohnheim's  brilliant 
work  in  pathologic  physiology,  the  descriptive  point  of  view  continued, 
despite  the  rise  of  bacteriology,  which  likewise  was  treated  by  pathol- 
ogists as  essentially  a  descriptive  science,  until  the  genius  of  Ehrlich 
offered  the  impetus  to  a  dynamic  conception. 

In  investigation,  the  descriptive  point  of  view  is  now  subordinate, 
but  in  teaching  it  still  persists.  The  student  in  physiology,  in  many 
schools  with  well-equipped  laboratories,  never  works  with  an  animal 
higher  than  the  frog.  Such  a  course  in  electrophysiology,  essentially 
a  course  in  physics,  with  a  few  exercises  devoted  to  the  use  of  mechan- 
ical models  and  perhaps  a  few  amphitheater  demonstrations,  is  con- 
sidered sufficient  training  for  the  work  which  soon  follows,  in  the 
instruction,  for  example,  in  physical  diagnosis.  The  student  enters  on 
the  latter  work,  which  many  consider  the  most  difficult  part  of  their 
course,  with  no  first-hand  knowledge  of  the  important  phenomena  of 
circulation  and  respiration,  which  might  readily  have  been  presented 
by  the  use  of  mammals.  One  of  the  most  useful  instruments  of  the 
physician,  the  stethoscope,  of  great  value  also  in  the  teaching  of  physi- 
ology, is  seldom  utilized.  In  many  courses  the  physiology  of  respira- 
tion and  circulation  is  completed  without  the  student  having  heard  the 
respiratory  murmur  or  the  heart  sounds.  The  physiology  of  the 
kidney,  the  pancreas  and  the  ductless  glands  is  taught  by  lecture  only, 
or  by  an  occasional  amphitheater  demonstration.  In  such  departments 
we  usually  find  the  man  who  lectures  four  or  five  times  a  week  and 
leaves  the  laboratory  work  to  his  assistants.  As  a  teacher  of  pathology 
I  believe  the  "  frog "  course,  unaccompanied  by  work  on  mammals, 
worse  than  nothing,  for  the  student  thinks  "  frog  "  and  not  physiology. 
8 


98  MEDICAL   BESEABCH   AND    EDUCATION 

He  gets  his  mammalian  physiology  for  the  first  time  when  he  takes  his 
course  in  experimental  pharmacology.  If  the  latter  course  is  not 
provided  by  the  curriculum — and  unfortunately  in  many  schools  it  is 
not — he  does  not  get  it  until  as  a  practitioner  he  experiments  on  man. 

Bacteriology,  one  of  the  most  modern  of  the  medical  sciences,  suffers 
likewise  from  the  descriptive  method.  It  is,  in  the  majority  of  schools, 
a  course  in  the  descriptive  botany  of  the  fungi.  It  is  true  that  the 
student  actually  handles  the  bacteria,  studies  their  morphology  and 
observes  their  behavior  in  artificial  media,  but  their  behavior  in  the 
animal  body  is  left  to  lectures.  The  all-important  lessons  of  bac- 
teriology— the  problems  of  infection  and  immunity — the  student  has 
no  opportunity  to  study  at  first  hand.  What  a  live  subject  bacteriology 
may  be  for  the  student  is  seen  in  those  few  courses  in  which  he  repro- 
duces in  animals  the  lesions  caused  by  the  microorganisms  which  he 
studies,  and  carries  out  those  experiments  which  illustrate  the  funda- 
mental principles  of  immunity.  He  can  have  no  better  training  in  the 
experimental  method  than  that  which  comes  from  following  half  a 
dozen  different  bacteria  from  pure  culture  through  the  lesions  which 
each  prodiices  in  an  animal  and  back  again  to  pure  culture.  Likewise, 
the  experimental  study  of  active  and  passive  immunity,  even  if  the 
latter  be  only  the  simple  testing  of  the  protective  power  of  diphtheria 
antitoxin,  is  invaluable.  If  to  these  is  added  the  practical  study  of 
hemolysins,  agglutinins,  precipitins  and  of  the  phenomena  of  hyper- 
susceptibility,  bacteriology  as  applied  to  medicine  is  actually  taught. 
From  the  practical  point  of  view,  the  training  offered  by  animal  inocu- 
lations is  of  the  greatest  importance  for  the  proper  appreciation  of  the 
principles  of  asepsis  in  surgery,  while  the  work  in  immunity  aids  the 
student  to  grasp  intelligently  the  pathology  and  therapy  of  the  trans- 
missible diseases. 

It  is  a  matter  of  great  doubt  if  in  the  better  schools  to  which  stu- 
dents come  with  a  general  training  in  biology  it  is  necessary  to  give  as 
much  time  to  the  purely  morphologic  study  which  consumes  so  much 
time  in  the  average  course  in  bacteriology.  Certainly  this  phase  of 
the  subject,  with  the  abundance  of  excellent  text-books  which  we 
possess,  does  not  demand  the  number  of  lectures  usually  devoted  to  it. 
The  present  methods  do  not  give  the  student  an  adequate  general  con- 
ception of  the  role  bacteria  play  in  disease,  and  of  specific  effects  they 
have  no  knowledge  which  they  can  readily  apply  to  their  work  in 


TEE   EXPEEIMENTAL   METHOD  99 

pathology.  As  a  teacher  of  pathology  my  experience  has  been  such 
that  I  take  it  for  granted  that  the  student  knows  something  about  the 
tubercle  bacillus,  the  diphtheria  bacillus  and  the  gonococcus;  but  as  to 
the  other  pathogenic  bacteria  I  have  found  it  just  as  well  to  assume 
that  their  knowledge  will  not  lessen  the  labor  of  the  instruction  in 
pathology.  As  to  their  knowledge  of  the  difference  between  bacteria 
and  protozoa  it  is  enough  to  say  that  the  ameba  of  dysentery  is  usually 
designated  as  Bacillus  amebce  or  Bacillus  amebcB  coli,  and  Bacillus 
malarice  is  not  uncommon.  If  the  biologist  and  the  modern  physiol- 
ogist can  utilize  our  common  protozoa  in  an  experimental  course,  why 
not  the  bacteriologist  to  such  an  extent  at  least  that  the  medical  student 
may  learn  the  difference  between  a  bacterium  and  protozoon  ? 

And  what  is  to  be  said  of  pathology?  I  may  perhaps  be  criticized 
for  what  I  have  said  about  physiology  and  bacteriology  on  the  basis 
that  I  have  not  taught  these  subjects  and  am  not  familiar  with  the 
difficulties  which  they  present.  This  criticism  certainly  can  not  hold 
when  I  say  that  I  consider  pathology,  as  it  is  usually  taught,  the  most 
forlorn  course  in  the  medical  curriculum.  Lectures  in  great  abun- 
dance, illustrated  by  museum  specimens  enclosed  in  fluid  and  glass  and 
sections  of  diseased  tissues  sandwiched  between  glass  is  the  story  in  nine 
out  of  ten  courses.  Even  when  fresh  material  is  supplied  in  satisfactory- 
amount,  a  gap  still  remains — that  great  gap  representing  altered 
physiology.  I  do  not  wish  to  decry  any  means  by  which  a  knowledge 
of  pathology  may  be  presented  to  the  student,  but  an  adequate  collec- 
tion of  specimens  representing  the  gross  and  microscopic  appearance 
of  diseased  tissues  should,  I  believe,  be  considered  as  only  the  essential 
minimum  of  equipment.  Neither  do  I  wish  to  minimize  the  impor- 
tance of  morphologic  study,  for  it  is  the  cornerstone  of  that  modern 
pathology  on  which  sound  diagnosis  and  rational  therapy  rest;  but 
the  teachers  of  men  who  are  to  spend  their  lives  in  the  study  of  the 
manifestations  of  altered  physiology  should  not  magnify  the  morpho- 
logic aspect  of  pathology  at  the  expense  of  the  dynamic.  This  phase 
of  my  subject  in  so  far  as  it  refers  to  investigation  has  been  very  ably 
discussed  from  the  point  of  view  of  the  chemist  by  Professor  A.  E. 
Taylor;  and  the  possibilities  of  physiologic  methods  in  teaching  pathol- 
ogy to  small  groups  of  students  have  been  clearly  demonstrated  by 
Professor  "W.  G.  MacCallum.  So  ably  have  they  presented  their  claims 
that  I  can  add  but  little  that  is  original.     My  personal  experience  may. 


100  MEDICAL   EESEABCH   AND   EDUCATION 

however,  be  of  some  value  as  an  illustration  of  the  evolution  of  a  point 
of  view.  Trained  as  a  morphologist  of  the  most  uncompromising  type, 
I  became  interested,  after  several  years,  in  the  methods  of  experi- 
mental pathology  and  gradually  awakened  to  the  importance  of  the 
investigation  of  altered  function.  A  desire  for  a  greater  knowledge  of 
the  methods  of  physiology  and  chemistry  followed.  At  first  this  new 
knowledge  was  utilized  only  in  investigation,  but  a  troubled  conscience 
soon  led  to  its  use  in  the  teaching  of  pathology.  At  first,  experimental 
demonstrations  before  the  entire  class  Avere  introduced  here  and  there 
in  my  courses,  but  in  such  a  fragmentary  way  that  they  were  of  no 
more  value  to  the  student  than  the  usual  set  demonstration  of  the 
chemist.  This  year,  for  the  first  time,  I  found  myself  with  sufficient 
space,  •equipment,  time  and  assistants  to  inaugurate  a  systematic  course 
in  experimental  pathology  and  pathologic  physiology  in  such  a  manner 
that  each  student  would  get  something  out  of  it.  Without  going  into 
the  details  I  may  say  that  by  giving  two  hours  a  week  to  the  course  and 
dividing  the  class  in  two  sections,  each  student  of  a  class  of  ninety  men 
had  fourteen  exercises  of  an  hour  each,  and  by  presenting  in  each  hour 
five  different  demonstrations  simultaneously,  no  one  demonstration 
group  numbered  more  than  nine  men.  That  is,  about  seventy  experi- 
mental procedures,  phenomena  or  lesions,  were  shown  each  man,  for 
«ach  of  which  he  had  twelve  minutes  and  was  only  one  of  a  group  of 
nine.  I  give  these  figures  to  show  the  possibility  of  carrying  out 
experiments  of  this  nature  with  large  classes.  The  planning  of  the 
course  is  no  small  matter  and  the  labor  of  preparation  is  great,  but  the 
actual  demonstrations  are  not  difficult,  and  even  if  they  were  the 
change  in  the  attitude  of  the  student  toward  pathology  which  such  a 
course  brings  about  makes  it  well  worth  while. 

These  demonstrations  included  the  presentation  of  necrosis  and  the 
degenerations ;  inflammation  and  repair ;  blood-destruction  and  jaundice ; 
thrombosis,  embolism  and  infarction ;  certain  lesions  of  the  heart,  lung, 
stomach  and  intestines,  liver,  pancreas  and  kidney;  the  problems  of 
infection  and  immunity,  of  shock  and  hemorrhage,  and  the  physiology 
of  the  ductless  glands.  Physiologic  methods  of  graphic  registration 
were  used  whenever  possible,  changes  in  the  urine  and  other  secretions 
demonstrated,  and  the  methods  of  clinical  diagnosis  emphasized.  A 
few  details  of  some  of  the  exercises  may  illustrate  the  advantages  of 
this  course.      The  pathology  of  blood-destruction  and  jaundice,  the 


SCRIPPS 

BiOLCGlCAL  RESHAKcs- 


THE   EXPERIMENTAL   METHOD  101 

circulatory  changes  in  heart  disease,  and  the  pathology  of  the  pancreas 
are  subjects  always  difficult  for  the  student  to  grasp;  and,  moreover, 
almost  impossible  of  demonstration  by  morphologic  methods.  The 
exercises  on  these  subjects  may  therefore  serve  as  examples.  Blood- 
destruction  and  jaundice  were  illustrated  by  five  demonstrations:  (1) 
the  production  of  hemoglobinemia  and  hemiglobinuria  by  the  admin- 
istration of  crotalus  venom,  and  (2)  the  injection  of  hemolytic 
immune  serum.  The  associated  changes  in  the  spleen  and  other  organs 
vrere  demonstrated,  as  was  also  the  laking  of  the  blood  in  centrifuged 
serum.  The  naked-eye  appearance  of  the  urine  was  contrasted  with 
that  of  (3)  hematuria  due  to  cantharidin,  as  were  also  the  albumin 
content  and  sediment  of  the  two  types  of  urine,  and  the  use  of  the 
spectroscope  was  demonstrated.  By  test-tube  experiments  the  phe- 
nomena of  (4)  hemolysis  and  hemagglutination  were  explained,  and 
thus  the  theory  graphically  brought  into  relation  with  the  changes  in 
the  animal  body;  (5)  obstructive  jaundice  due  to  ligation  of  the  com- 
mon bile-duct  was  shown,  the  urine  of  this  animal  contrasted  with 
that  of  the  hemoglobinuric  animals  as  to  the  presence  of  bile  and 
albumin,  and  by  comparing  these  animals  the  clinical  signs  of  obstruc- 
tive and  hemolytic  jaundice  were  clearly  shown  by  examination  of  the 
skin  and  conjunctiva. 

In  the  exercise  on  cardiovascular  disturbances  the  changes  in  heart 
action,  blood-pressure,  pulse-rate  and  volume,  and  in  respiration  as  a 
result  of  experimental  (1)  aortic  insvifficiency,  (2)  mitral  stenosis, 
(3)  hydropericardium,  (4)  injury  to  myocardium  and  (5)  edema  of 
the  lungs,  were  graphically  demonstrated  by  the  use  of  a  kymograph. 

Acute  diseases  of  the  pancreas  were  illustrated  by  (1)  experimental 
acute  hemorrhagic  and  (2)  gangrenous  pancreatitis  due  to  the  injection 
of  bile,  with  (3)  the  correlated  fat  necrosis.  The  relation  of  the 
pancreas  to  diabetes  and  the  theory  of  internal  secretion  were  demon- 
strated by  contrasting  the  results  of  (4)  extirpation  of  the  pancreas 
with  (5)  ligation  of  the  pancreatic  ducts.  The  fermentation  and 
Pehling's  tests  applied  to  the  urine  of  all  these  animals  offered  a  vivid 
picture  of  the  relative  influence  of  different  types  of  injury  of  the 
pancreas. 

These  three  exercises  are  examples  of  the  opportunities  offered  by 
this  method  of  teaching.  The  advantages  of  its  application  to  the 
problems  of  nephritis,  the  disturbances  of  the  ductless  glands  and  the 


102  MEDICAL   BESEAECH   AND   EDUCATION 

principles  of  infection  and  immunity  are  evident.  No  other  part  of 
my  teaching  experience  has  ever  given  me  so  much  satisfaction  with 
the  attitude  of  the  student,  and  in  no  other  course  have  I  felt  so  certain 
that  I  was  giving  him  what  he  wanted  and  needed.  Such  a  course  is, 
after  all,  as  near  an  approach  to  clinical  methods  as  one  can  attempt 
in  the  laboratory.  The  physician  studies  the  altered  functions  of  his 
patient  by  direct  observation  and  by  all  the  methods  which  biology, 
physics  and  chemistry  have  brought  to  bear  on  diagnosis;  he  summar- 
izes the  results,  correlates  them,  ponders  over  them  and  arrives  at  a 
conclusion  which  is  based  largely  on  the  fundamental  experience  of 
pathologic  anatomy.  His  work  really  represents  the  first,  the  oldest 
and  the  most  important  application  of  pathologic  physiology.  Is  it 
not  rational,  therefore,  to  prepare  the  student  for  his  study  of  the 
pathologic  physiology  of  man  by  similar  studies  on  the  lower  mammals? 
To  let  him  produce,  or  see  produced,  certain  anatomic  lesions  and  study 
the  alterations  of  function  which  result,  applying  thereto  many  of  the 
clinical  methods,  and  eventually  at  autopsy  to  correlate  the  disturb- 
ances in  physiology  with  the  anatomic  changes,  is,  I  believe,  a  most 
valuable  preparation  for  clinical  study,  in  that  it  bridges  the  great  gap 
between  pathologic  anatomy  and  clinical  observation. 

Another  phase  of  the  teaching  of  pathology  which  may  be  criticized 
is  the  presentation  of  pathologic  anatomy.  Diseased  organs  are  studied 
from  the  point  of  view  of  changes  in  morphology,  color  and  consistence, 
without  attempt  to  associate  physiologic  disturbances.  In  many 
schools  no  systematic  work  in  gross  pathology  is  offered  after  the  second 
year,  and  even  in  the  second  year  it  is  usually  a  museum  course  with 
no  systematic  drill  in  fresh  appearances.  Some  schools  have  improved 
the  situation  by  obligatory  autopsy  work  and  clinico-pathologic  con- 
ferences in  the  third  and  fourth  years.  Also  the  museum  material 
has  had  some  life  instilled  into  it  by  adopting  the  "case"  system  of 
presenting  organs  illustrating  the  associated  lesions  of  any  one  disease 
with,  at  the  same  time,  the  clinical  history  and  microscopic  prepara- 
tions. But  all  these  improvements  leave  the  work  a  demonstration 
course.  The  student  can  obtain  an  adequate  knowledge  of  morbid 
anatomy  only  by  following  the  example  of  the  young  pathologist ;  that 
is,  by  studying  at  first  hand  the  naked-eye  appearance  of  fresh  organs, 
arriving  at  some  conclusion,  and  immediately  verifying  it,  or  otherwise, 
by  the  use  of  the  freezing  microtome.      This  is  the  true  experimental 


THE   EXPEHIMENTAL   METHOD  103 

method — observation,  hypothesis,  experiment,  deduction.  It  is  per- 
haps best  combined  with  the  work  of  the  third  and  fourth  year  of 
medicine,  after  the  student  has  had  a  year  of  fundamental  pathology, 
though  if  time  allows  it  can  also  be  used  in  the  second  year^  During 
the  past  four  months  I  have  used  it  with  my  third-year  class  and  have 
had  the  most  gratifying  results.  Placed  in  a  room  with  the  fresh 
material  before  them,  with  scales,  measures,  the  necessary  dissecting 
instruments,  a  bacteriologic  outfit,  stains  and  reagents  for  microchem- 
ical  reactions,  an  abundance  of  text-books  on  all  branches  of  medicine, 
and  a  laboratory  attendant  at  the  freezing  microtome,  the  men  have 
worked  out  their  own  diagnoses  at  first  hand.  No  demonstrations  were 
given  and  no  aid,  except  in  guiding  methods  of  procedure  and  by  occa- 
sional pertinent  questions.  At  the  end,  diagnoses  were  checked,  and 
each  student's  general  knowledge  of  the  lesions  he  had  studied  was 
determined  by  a  few  leading  questions  as  to  etiology,  associated  condi- 
tions, complications,  sequels  and  important  clinical  symptoms.  The 
eager  attitude  of  the  class  toward  this  course  has  been  sufficient  evi- 
dence of  its  value. 

Professor  Chiari,  to  whom  so  many  of  our  teachers  of  pathology 
owe  their  early  training,  during  his  recent  visit  to  this  country,  investi- 
gated our  methods  of  teaching  pathology.  The  account  of  his  impres- 
sions published  on  his  return  to  Germany  is  for  the  most  part  very 
pleasing,  but  he  criticizes  justly  the  insufficient  use  of  fresh  autopsy 
material. 

"We  have  not  the  wealth  of  fresh  autopsy  material  offered  by  the 
pathologic  institutes  of  Germany,  but  that  which  we  have  is  too  fre- 
quently used  for  perfunctory  demonstration  or  for  second-hand  study 
as  beautifully  mounted  and  labeled  museum  preparations  and  not  suffi- 
ciently utilized  for  first-hand  observation  and  manipulation  by  the 
student.  The  use  of  fresh  material  and  the  freezing  microtome  go 
far  to  wean  the  student  from  his  "  reverence  for  authority  "  and  his 
faith  in  the  lecture  and  to  force  him  to  observe  and  think  for  himself. 

Physiologic  chemistry  and  experimental  pharmacology,  as  given 
in  our  best  schools,  are,  I  believe,  the  most  satisfactory  of  our  labora- 
tory courses.  Presented,  in  most  instances,  in  a  vigorously  scientific 
manner,  with  the  student  carrying  on  exact  quantitative  estimations  and 
using  graphic  methods  of  registering  results,  and  himself  frequently 
the  object  of  experiment,  these  courses  fulfil  all  the  rules  of  the  experi- 


104  MEDICAL   RESEARCH   AND    EDUCATION 

mental  method  and  force  on  the  student,  as  no  other  course  does,  the 
practical  importance  of  this  method.  To  one  who  was  taught  by  the 
methods  of  the  old  "  medical  chemistry  "  it  is  most  stimulating  to  see 
an  entire  class  in  modern  physiologic  chemistry  study  the  influence  of 
a  protein,  a  fat  or  a  green  diet,  of  a  nuelein  diet  on  purin  output,  of  a 
heavy  protein  diet  on  urea  output,  and  of  starvation  on  total  nitrogen 
and  acetone  elimination.  In  these,  as  well  as  in  other  procedures,  as 
individual  calorimetry  with  the  respiration  apparatus,  the  student  is  the 
investigator  as  well  as  the  experimental  animal.  Such  experiments  are 
now  extensively  carried  out  in  a  few  courses,  and  when  supplemented 
by  the  study  of  phloridzin  glycosuria,  pancreatic  diabetes  and  other 
experimental  conditions  in  animals,  give  a  knowledge  of  the  funda- 
mental principles  of  metabolism  and  of  practical  physiologic  chemistry 
which  was  not  dreamed  of  by  the  student  of  ten  years  ago.  Such 
courses  lead  one  to  believe  that  the  rapidly  approaching  closer  union 
of  hospital  and  school  will  lead  to  the  next  step,  the  opportunity  for 
small  classes  to  study  the  metabolism  of  patients  in  the  hospital  ward. 
The  modern  course  in  experimental  pharmacology,  unfortunately  at 
present  not^iven  in  all  our  better  schools,  is,  I  believe,  the  most  valu- 
able part  of  the  first  two  years  of  laboratory  work.  Coming  as  it 
usually  does  in  the  latter  part  of  the  second  year,  when  the  student  is 
completing  or  has  completed  his  physiology  and  pathology,  it  offers 
him  the  last  opportunity,  before  he  approaches  the  clinic,  to  review 
normal  functions  and  to  study  the  manner  in  which  various  agents  may 
alter  them.  And  in  those  courses  which  are  not  merely  exercises  in 
testing  the  action  of  drugs,  but  in  which  abnormal  conditions  are  pro- 
duced and  measures  for  their  treatment  or  care  are  applied,  pathology 
as  well  as  physiology  is  reviewed  and  the  fundamental  principles  of 
therapeutics  thoroughly  impressed  on  the  student's  mind.  Not  only 
medicine,  but  surgery,  benefits  by  such  a  course,  for  the  study  of  the 
influence  of  anesthetics  and  of  the  production  and  treatment  of  shock, 
collapse  and  hemorrhage  carries  the  student  well  into  the  realms  of 
clinical  surgery.  I  refer,  naturally,  not  to  demonstration  courses,  but 
to  those  in  which  the  procedures  are  actually  carried  out  by  the  class ; 
a  course  without  which  no  school  can  be  considered  as  fulfilling  its 
duty  to  the  future  practitioner  of  medicine,  for  it  not  only  continues 
the  training  in  methods,  but  gives  the  student  "  an  insight  into  the 
possibilities  and  limitations  of  treatment  by  drugs  which  will  protect 


THE    EXPEEIMENTAL    METHOD  105 

him  from  a  pessimistic  nihilism  on  the  one  hand,  and  even  more  impor- 
tant, from  uncritical  enthusiasm  on  the  other.  The  student  thus 
trained  will  be  less  likely  to  fall  a  prey  to  the  proprietary-medicine 
manufacturer  and  the  nostrum  monger  than  the  physician  who  has 
obtained  all  his  knowledge  concerning  the  action  of  drugs  from  books, 
lectures  or  the  circulars  of  manufacturers"  (Barker). 

In  presenting  this  criticism  I  am  not  unmindful  of  the  recent  great 
advance  in  the  utilization  of  laboratory  teaching,  and  I  realize  fully  that 
suitable  equipment  for  teaching  must  precede  the  elaboration  of  meth- 
ods of  teaching.  This  equipment  we  now  have  in  all  good  schools  and 
I  feel  very  strongly  that  the  time  has  arrived  for  the  heads  of  the  labo- 
ratory departments  to  justify  its  great  expense  by  so  conducting  their 
courses  as  to  satisfy,  on  the  one  hand,  the  students  receiving  the  instruc- 
tion, and,  on  the  other,  the  trustee  or  others  providing  the  equipment. 
But,  above  all,  they  must  themselves  be  satisfied  that  their  courses,  col- 
lectively, leave  no  gaps  which  might,  with  a  little  thought  and  a  little 
cooperation,  be  filled.  Some  of  these  gaps,  as,  for  example,  those  I 
have  mentioned  in  connection  with  bacteriology  and  pathology,  could 
be  filled  by  new  departments  of  immunology  and  pathologic  physiology, 
but  the  already  overburdened  medical  curriculum  can  not  yield  more 
time.  Correlation  between  various  departments  and  a  rearrangement 
of  old  courses  on  a  modern  basis,  with  the  object  of  training  for  power 
rather  than  knowledge,  must  be  one  of  the  remedies.  The  present  evil 
is  the  result  of  a  lack  of  general  supervision.  Professional  dignity 
frowns  on  interference  in  the  affairs  of  a  department,  and  suggestions 
are  not  always  kindly  received.  It  is  probably  for  this  reason — fear  of 
offending  a  colleague — that  criticism  has  seldom  been  brought  to 
bear  on  this  point ;  indeed,  it  appears  to  have  escaped  the  all-seeing  eye 
of  the  able  representative  of  the  Carnegie  Foundation.  One  remedy, 
therefore,  is  open  criticism  backed  with  authority,  and  that  authority 
should  reside  in  a  committee  of  the  governing  body  of  the  university. 
This  is  the  most  direct  way  to  bring  about  a  proper  correlation,  but  not 
perhaps  the  best  way. 

Another  method  is  by  voluntary  cooperation  on  the  part  of  the 
heads  of  the  laboratory  departments,  with  free  criticism  one  of  another 
and  helpful  suggestions  for  each  other's  department.  This  fails  some- 
times, when  a  considerable  number  of  years  separate  the  training  of 
one  department  head  from  that  of  another,  but  usually  the  spirit  of 


106  MEDICAL   EESEABCH   AND   EDUCATION 

mutual  helpfulness  wins.  Our  medical  sciences  are  not,  for  the  most 
part,  so  widely  separated  that  the  members  of  one  department  are 
totally  ignorant  of  the  methods  of  another.  Their  interrelation  is  best 
illustrated  by  the  development  of  embryology  in  the  departments  of 
anatomy,  physiology  and  zoology  simultaneously;  by  the  influence  of 
pathology  on  physiology  and  on  the  development  of  certain  phases  of 
normal  histology;  by  the  position  which  bacteriology  and  protozoology 
occupy  in  the  departments  of  pathology  and  hygiene;  by  the  develop- 
ment of  a  new  science,  modern  pharmacology,  based  on  the  application 
of  the  methods  of  chemistry  and  physiology  to  empirical  therapeutics; 
and  by  immunology,  as  its  followers  now  term  it,  which  demands  the 
methods  of  practically  all  the  medical  sciences. 

Despite  this  history  of  development  and  mutual  relation  there  is  a 
tendency,  not  only  in  teaching,  but  in  investigation,  to  separate  sharply 
each  of  these  into  an  independent  science  of  medicine  to  the  great  detri- 
ment of  that  which  should  be  the  scientific  aim  of  all,  the  development 
of  the  science  of  clinical  medicine.  Even  though  this  last  science  is 
to  reach  its  perfection  only  through  the  efforts  of  men  actually  engaged 
in  clinical  research,  as  is  the  opinion  of  Dr.  S.  J.  Meltzer,  such  men 
must  receive  every  advantage  of  training  in  the  fundamental  medical 
sciences,  and  not  only  this,  but  from  the  teachers  of  such  branches  they 
must  receive  so  much  of  the  scientific  spirit  that  they  will  carry  some 
of  it  with  them  into  their  clinical  work.  I  do  not  mean  by  this  that 
clinical  surgery  and  medicine  have  not  men  of  scientific  methods  and 
investigators  of  prominence;  I  mean  rather  that  they  would  have  more 
if  the  teachers  of  the  first  two  years  so  correlated  their  work  as  to  force 
on  the  student  the  practical  use  of  their  methods  in  the  investigation 
of  clinical  problems,  or,  what  is  simpler  still,  demonstrated  the  relation 
which  the  methods  of  one  course  bear  to  those  of  another  course  in  the 
explanation  of  the  phenomena  of  abnormal  function.  This  latter  is 
particularly  the  opportunity  of  the  courses  in  physiology,  pathology  and 
pharmacology.  I  once  taught  in  a  school  in  which  these  courses  were 
given  to  the  same  class  in  one  year.  The  heads  of  the  departments 
were  men  of  about  the  same  age,  of  the  same  general  type  of  training 
and  each  interested  in  demonstrating  the  value  of  the  method  of  his 
particular  laboratory  course  as  a  training  for  clinical  medicine.  "We  so 
arranged  our  courses  that  the  presentation  of  the  pathology  of  certain 
organs  was  frequently  preceded  or  followed  in  either  the  laboratory  of 


TEE   EXFEBIMENTAL   METHOD  107 

physiology  or  pharmacology  by  a  demonstration  of  such  functions  as 
could  be  graphically  shown,  with,  whenever  possible,  disturbances  of 
such  functions  due  to  the  action  of  drugs  or  experimental  injury.  The 
benefit  of  such  cooperation  can  not  be  denied  and  illustrates  a  second 
of  the  possible  remedies  for  the  present  isolation  of  our  laboratory 
courses. 

Another  important  phase  of  this  subject  is  that  of  the  relation  of 
investigation  to  teaching.  If  one  examines  courses  in  the  same  subject 
in  a  number  of  schools,  it  is  found  that  those  which  are  best  presented 
from  the  point  of  view  of  the  experimental  method  are  under  the  con- 
trol of  men  actively  engaged  in  research  work.  Such  men  are  alive  to 
the  advantages  of  new  methods  in  their  ovm  subject  and  of  new  ways 
of  applying  old  methods.  Ever  thinking  and  scheming  about  methods 
of  acquiring  new  knowledge  for  themselves  and  their  science,  they 
appreciate  better  than  does  the  non-investigator  that  which  will  aid  the 
student  to  acquire  knowledge,  and  in  their  teaching  they  bring  to  bear 
on  the  problems  which  the  student  has  to  face  the  same  methods  of 
attack  which  they  use  in  their  own  researches.  On  the  other  hand, 
one  finds  that  the  perfunctory  routine  laboratory  courses,  with  a  pro- 
fusion of  lectures,  are  by  the  men  who  never  or  only  occasionally  con- 
tribute to  the  literature  of  their  science.  Under  men  of  the  first  type, 
one  finds  assistants  of  the  same  point  of  view,  who,  ever  enthusiastic 
about  their  duties  as  teachers,  nevertheless  find  time  for  research.  And 
it  is  of  further  interest  that  in  these  departments  assistants  do  not 
remain  for  long  periods,  or  at  least  if  they  do  it  is  of  their  own  desire, 
for  they  are  soon  called  to  independent  positions  in  other  institutions. 
In  the  department  of  the  second  type,  the  teaching  is  a  routine  which, 
so  the  assistants  say,  gives  no  time  for  investigation;  they  remain 
assistants  indefinitely.  So,  likewise,  is  it  with  the  student  taught 
under  these  two  conditions.  The  student  who  knows  that  he  is  work- 
ing in  a  department  actively  emphasizing  new  methods  and  striving  to 
develop  new  truths,  knows  that  his  instruction  is  presented  on  the 
same  basis,  and  thus  receives  that  stimulus  and  inspiration  which 
insures  his  approaching  clinical  medicine  with  a  proper  appreciation 
of  the  scientific  method.  The  student  under  circumstances  of  the 
second  order  has  no  incentive  other  than  that  of  acquiring  a  knowledge 
sufficient  to  allow  him  to  pass  an  examination. 

This  last  condition  of  affairs  we  will,  however,  have  with  us  until 


108  MEDICAL   EESEAECH   AND   EDUCATION 

appointive  bodies  realize  that  "  it  is  a  disgrace  to  a  university  to 
appoint  a  man  as  professor  chiefly  because  he  is  a  '  good  teacher  ' ;  such 
a  man  may  be  a  good  teacher^  but  only  investigators  can  give  university 
instruction"  (Minot). 

I  have  seen  somewhere,  in  an  essay  on  Russian  politics,  if  I 
remember  rightly,  a  quotation  from  the  Greek,  to  the  effect  that  the 
character  of  a  city  is  determined  by  the  character  of  the  men  whom  it 
crowns.  So,  likewise,  is  the  educational  policy  of  a  university  reflected 
in  the  character  of  the  teachers  it  appoints. 

I  have  often  thought  that  our  departments  of  biologic  chemistry 
and  experimental  pharmacology  forcibly  illustrate  the  importance  of 
the  investigator  as  a  teacher.  With  few  exceptions,  they  are  manned 
by  active  investigators  and  from  the  point  of  view  of  medical  pedagogy 
are  most  satisfactory.  They  represent,  as  now  organized,  the  most 
recently  developed  of  the  medical  sciences,  and  have  emerged  directly 
from  the  fields  of  most  active  investigation  in  physiology  and  chemistry. 
They  have  no  vast  theoretical  literature  back  of  them,  no  traditions  as 
to  methods  of  teaching,  but  they  have  established  their  own  methods  on 
the  basis  of  observation  and  experiment.  "  Medical  chemistry  "  and 
"  therapeutics  "  were  once  taught  by  "  good  teachers,"  but  the  investi- 
gator in  physiology  and  chemistry  has  transformed  them  into  sciences 
of  university  rank  to  which  the  former  narrow  terminology  no  longer 
applies. 

These  three  factors — authoritative  control  to  arrange  correlation, 
cooperation  by  department  heads,  and  the  appointment  of  teachers  who 
are  also  investigators — are  fundamental  in  the  application  of  the 
methods  of  experimental  medicine  to  proper  teaching.  Two  other  fac- 
tors, however,  are  concerned.  These  are  closely  related.  One  is  the 
question  of  electives  and  the  other  the  question  of  actual  research  by 
the  student.  The  first,  necessary  for  any  proper  attempt  at  correlation, 
is  obligatory  if  the  student  is  to  work  independently,  even  in  a  small 
way,  as  an  investigator.  As  the  advisability  of  giving  the  student  the 
latter  opportunity  is  still  a  disputed  point,  however,  it  may  be  discussed 
first.  As  every  teacher  knows,  each  class  contains  a  considerable  num- 
ber of  men  who  desire  to  pursue,  to  a  greater  extent  than  the  conven- 
tional course  allows,  work  on  certain  subjects  or  by  special  methods,  or 
less  frequently,  perhaps,  they  desire,  and  are  usually  well  qualified  to 
undertake,  minor  investigative  work.    To  the  former,  as  well  as  to  the 


THE   EXPEBIMENTAL   METHOD  109 

latter,  any  effort  spent  in  work  beyond  that  given  the  entire  class  be- 
comes, necessarily  for  them,  the  acquirement  of  the  methods  of  re- 
search, and  as  this  means  a  knowledge  of  the  exact,  painstaking  meth- 
ods by  which  the  realms  of  the  unknown  are  explored  it  is  an  exercise 
which  prepares  the  student  for  the  daily  routine  research  work  of  the 
physician  who  truly  practises  his  profession.  As  a  training  for  future 
work  its  value  is  definitely  known  and  the  increased  zest  and  enthusi- 
asm exhibited  towards  their  medical  work  by  men  who  have  had  this 
opportunity  are  always  evident.  Pedagogically,  therefore,  it  would 
seem  advisable  that  every  student  should  have  the  opportunity  for 
minor  research,  in  order  that  he  may  become  acquainted  at  first  hand 
with  the  careful  methods  of  experimental  medicine.  The  bearing  of 
the  tangible  results  of  his  work  on  the  subject  investigated  is  a  matter 
of  little  or  no  importance;  the  vital  thing  is  the  increased  power  which 
he  himself  acquires.  If  the  student  is  to  have  such  opportunity  the 
elective  system  is  necessary.  This  principle  has  been  recognized  by 
those  in  control  of  this  school,  and  you  have  in  your  fourth  year  the 
first  attempt  to  arrange  wisely  for  research  work  as  well  as  for  con- 
centration of  work  on  related  subjects.  It  has  also  been  recognized  by 
the  Johns  Hopkins  Medical  School,  where,  however,  some  elective  work 
is  placed  in  each  year,  instead  of  being  limited  to  one  year.  It  is  too 
early  to  say  which  of  these  two  systems  is  the  better,  but  the  matter  is 
in  safe  hands  and  we  may  await  the  ultimate  decision  on  this  point 
with  the  knowledge  that  electives,  wisely  arranged  and  wisely  chosen, 
are  essential  to  proper  medical  education  and  must  eventually  be 
adopted  by  all  schools  of  the  first  rank. 

So  much  for  the  use  of  the  experimental  method  in  the  two  lab- 
oratory years.  This  method,  if  it  has  any  special  significance,  should 
bear  fruit  in  the  third  and  fourth  years,  the  periods  devoted  to  clinical 
teaching.  Are  our  clinical  departments  so  organized  that  they  are  pre- 
pared to  aid  the  student  in  his  development  along  scientific  lines?  A 
few  are,  but  for  the  most  part  the  clinician  returns  the  student  to  the 
methods  of  the  lecture-room  and  the  demonstration  and  gives  him  little 
opportunity  to  develop  his  pov/ers  of  personal  observation.  The  discus- 
sion of  this  phase  of  teaching  may  be  limited  to  the  department  of 
medicine,  as  contrasted  with  surgery  and  the  specialties,  though  what 
is  said  of  medicine  applies  equally  to  other  clinical  branches.  The  de- 
partment of  medicine  should  be  the  great  glory  of  the  medical  school, 


110  MEDICAL   BESEABCH   AND   EDUCATION 

and  the  method  of  instruction  in  all  preceding  courses  should  be  con- 
sidered as  contributing  to  the  proper  study  and  appreciation  of  the  ma- 
terial and  problems  of  clinical  medicine.  Pedagogically  considered, 
the  methods  of  study  in  the  earlier  years  should  give  the  student  the 
proper  point  of  view  for  approaching  any  diseased  condition,  and,  prac- 
tically, they  should  train  him  as  far  as  may  be  possible  in  the  actual 
methods  of  precision  used  in  the  clinic.  The  methods  of  the  diagnosti- 
cian are  those  used  in  procuring  all  scientific  data ;  that  is,  accurate  ob- 
servation and  experiment  with  logical  deduction.  His  observations  are 
of  two  kinds,  direct,  by  the  exercise  of  his  unaided  senses,  and  indirect, 
by  the  use  of  instruments  of  precision  and  various  laboratory  proced- 
ures. These  demand  methods  which  from  the  pedagogic  point  of  view 
are  in  no  way  different  from  the  methods  used  by  the  student  in  his 
laboratory  years. 

The  data  obtained,  either  directly  or  indirectly,  when  correlated  ac- 
cording to  the  rules  of  the  experimental  method,  lead  to  a  conclusion 
(diagnosis)  as  scientific  as  the  conclusions  of  the  investigator  in  the 
laboratory  of  physiology  or  pharmacology.  If  it  should  eventuate  that 
the  conclusion  is  erroneous,  it  is  not  the  fault  of  the  experimental  method, 
but  of  inadequate  methods,  insufficient  data  or  improper  deduction. 
Clinicians  of  long  practise  will  not  always  admit  that  the  data  on  which 
they  base  a  diagnosis  are  always  obtained  by  the  careful,  painstaking 
methods  of  scientific  observation.  They  imply  that  experience  gives  an 
added  sense,  forgetting  that  it  is  the  continuous  training  in  accurate 
observation  and  deduction  which  gives  them  the  power  to  make  and 
correlate  their  observations  rapidly  and  to  reach  their  conclusion  by  a 
"  short  cut "  not  possible  to  the  beginner.  This  idea  they  bring  into 
their  teaching  and  attempt  to  smooth  the  path  of  the  beginner  by  "  ex- 
plaining it  all"  in  lectures,  demonstrations  or  large  amphitheater 
clinics,  and  it  is  this  kindly  but  misguided  regard  for  the  student  which 
is  responsible,  I  believe,  for  most  of  the  faults  of  clinical  teaching.  I 
do  not  mean  to  minimize  the  importance  of  these  methods,  which  with 
the  lantern,  the  clinico-pathologic  conference,  the  "  case  "  system  and 
the  ward  class  all  have  their  place,  but  that  knowledge  of  medicine 
which  is  of  lasting  value  the  student  can  get  only  from  direct  study  of 
the  patient.  By  direct  study  I  do  not  mean  the  study  of  the  patient 
by  a  class,  no  matter  how  small,  but  the  study  of  one  patient  by  one 
student,  under  a  supervision  which  tells  him,  to  some  extent,  what  to 


THE   EXPERIMENTAL   METHOD  111 

do  and  how  to  do  it,  but  not  what  he  is  to  find;  in  other  words,  a  con- 
tinuance of  instruction  in  methods,  leaving  the  matter  of  deduction  in 
large  part  to  the  student  himself.  This  is  the  training  by  which  in  his 
hospital  days  or  in  private  practise  every  capable  physician  has  ob- 
tained his  knowledge  of  medicine,  and  it  is  a  training  which  every  med- 
ical school  ambitious  to  teach  medicine  properly  should  anticipate  in 
the  fourth  year  of  its  curriculum.  This  means,  as  has  been  frequently 
stated  by  the  advocates  of  this  method,  that  the  hospital  and  the  dis- 
pensary are  to  be  regarded  as  the  laboratories  of  clinical  medicine  and 
that  clinical  medicine  should  be  taught  by  the  scientific  method  com- 
mon to  all  laboratories.  That  this  method  can  be  successfully  carried 
out  is  shown  by  the  clinical  clerk  system  of  the  English  hospitals  and 
by  a  few  of  our  own  schools.  These  latter  have  done  a  good  work  in 
demonstrating  the  possibility  of  applying  the  method  to  large  classes, 
thus  removing  one  of  the  cliief  objections  to  its  use.  As  to  the  actual 
working  of  this  method  I  can  not  do  better  than  to  quote,  with  slight 
changes,  from  the  Carnegie  Eeport  on  Medical  Education: 

The  fourth  year  is  spent  in  the  hospital.  .  .  .  The  class  is  broken  up  into 
small  groups.  Each  student  gets  by  assignment  a  succession  of  cases,  for  a 
full  report  on  each  of  which  he  is  responsible;  he  must  take  the  history,  conduct 
the  physical  examination,  do  the  microscopic  and  other  clinical  laboratory  work, 
propound  diagnosis,  and  suggest  the  treatment.  For  this  purpose  he  has  easy 
access  to  the  hospital  wards.  His  "beds"  are  under  his  continuous  observation 
from  the  day  his  "patient"  is  admitted  until  the  day  of  discharge;  or  in  event 
of  death,  he  and  the  physician  ultimately  responsible  for  steps  taken  in  treat- 
ment repair  with  others  to  the  autopsy-room  to  bring  their  knowledge  to  the 
test.  .  .  .  Meanwhile  the  clinical  teaching  has  closely  followed  the  development 
of  the  case.  At  brief  and  regular  intervals  its  status  is  reviewed.  All  other 
members  of  his  group,  and  the  patient  too,  are  at  hand  when  the  student 
presents  his  report,  which  forms  part  of  the  permanent  record  of  the  case.  At 
every  point  he  has  been  checked  up;  the  instructor  in  charge  of  the  clinical 
laboratory  inspects  and  verifies  his  work  there;  the  clinical  instructor  here. 
Subject  to  this  control,  complete,  of  course,  from  the  standpoint  of  treatment 
followed,  the  student  is  a  physician  practising  the  technic  which,  it  is  hoped, 
may  become  his  fixed  professional  habit;  learning  through  experience,  as  indeed 
he  will  continue  to  learn — long  after  he  has  left  school — a  controlled,  system- 
atized, criticized  experience;  not  the  blundering,  helpless  "experience"  on 
which  the  didactically  or  demonstratively  taught  student  of  medicine  has  hitherto 
relied  for  a  slow  and  costly  initiation  into  the  art  of  medicine. 

If  with  this  is  combined  the  similar  study  of  a  constantly  changing 
dispensary  service,  the  student  has  an  opportunity  to  study  variety  and 
to  perfect  methods  of  diagnosis,  thus  supplementing  the  more  prolonged 
observations  in  the  ward. 


112  MEDICAL   BESEABCH   AND    EDUCATION 

The  conduct  of  such  a  course  brings  up  several  of  the  problems  now 
attracting  the  attention  of  all  who  are  interested  in  medical  education. 
It  can  not,  it  is  evident,  be  successfully  given  in  a  hospital  not  an  inte- 
gral part  of  the  university.  This  is  the  experience  of  all  schools  which 
have  attempted  it  in  hospitals  with  which  they  are  affiliated  but  in  which 
they  have  no  authority.  Questions  of  authority  over  patients,  of  equip- 
ment for  teaching,  of  laboratory  space  for  clinical  study,  all  indicate 
that  the  first  essential  is  the  possession  or  control  by  the  school  of  its 
own  hospital.  This  allows  an  easy  solution  of  all  problems :  Continuous 
service  and  freedom  in  the  appointment  of  clinical  teachers  come  as  a 
matter  of  course.  Teaching  and  investigation  can  be  carried  on  without 
interruption.  The  student  becomes  a  part  of  the  hospital  routine  and 
is  not  an  onlooker  with  limited  privileges.  The  laboratory  departments 
of  the  first  and  second  years  unite  to  aid  the  work  of  the  clinicians  in 
the  hospital.  Clinical  teachers  may  be  promoted,  if  deserving,  or  may 
be  called  from  any  part  of  the  country,  or  from  abroad;  the  choice  no 
longer  depends  on  local  hospital  appointments  or  on  selfish  interests 
and  friendships  of  local  consultants,  but  on  fitness,  eminence  and  skill. 

Teachers^  may  be  appointed  on  a  university  basis,  devoting  all  or 
most  of  their  time  to  the  care  of  the  patients,  to  teaching  and  to  in- 
vestigation. The  heads  of  the  departments  of  internal  medicine  and 
surgery  certainly  should  be  so  appointed.  Under  such  circumstances 
these  men  with  their  staffs  could  control  a  large  body  of  students  work- 
ing relatively  independently  among  the  patients  in  the  wards  and  in 
the  special  laboratories  in  or  near  the  wards.  In  these  clinical  labora- 
tories every  student  should  have  his  own  desk  and  outfit  for  micro- 
scopic, chemical  and  other  methods  of  examination.  Not  merely  appa- 
ratus for  the  simpler  tests  should  be  supplied,  but  as  well  every  facility 
for  prolonged  bacteriologic  examination,  animal  inoculation  and  de- 
tailed chemical  and  physiologic  study. 

Such  a  plan  insures  diagnostic  ability  and  therapeutic  skill  by 
training  the  powers  of  direct  observation  as  well  as  by  instructing  in 
the  methods  of  indirect  observation  through  the  use  of  instruments  of 
precision  and  the  procedures  of  the  chemical  and  biologic  laboratories. 
The  experimental  method  emphasized  in  the  laboratory  years  is  thus 
continued  through  the  clinical  years.  Laboratory  procedures  naturally 
fall  into  their  proper  place  in  relation  to  the  methods  of  direct  ob- 
servation, and  as  the  student  approaches  each  new  disease  in  the  spirit 


THE   EXPEEIMENTAL   METHOD  113 

of  the  investigator  and  not  as  an  onlooker  he  gains  a  point  of  view 
which  can  not  fail  to  have  an  important  bearing  on  his  work  as  a  prac- 
tising physician. 

Aside  from  the  question  of  expense,  the  only  argument  which  has 
been  raised  against  this  plan  is  that  the  patient  might  suffer.  This 
is  denied  by  all  who  have  had  experience  in  a  teaching  hospital,  and  on 
this  point  we  have  the  published  statements  of  a  well-known  surgeon, 
the  head  of  a  training  school  for  nurses  and  of  the  committee  appointed 
to  investigate  the  relations  between  the  hospitals  and  the  medical 
schools  of  London.  All  agree  that  the  care  of  the  patient  and  the 
routine  of  hospital  work  is  on  a  higher  level  in  teaching  than  in  non- 
teaching  hospitals;  and  these  opinions  take  no  account  of  the  advantage 
to  the  public  at  large  of  producing  better  physicians. 

Whatever  has  been  said  about  the  instruction  in  internal  medicine 
applies  with  equal  force  to  surgery,  pediatrics  and  obstetrics.  These 
four  subjects  constitute  the  backbone  of  medical  knowledge,  and  the 
last  three  deserve  a  word  of  comment.  Pediatrics,  frequently  served 
by  special  hospitals,  is  amenable  to  the  same  individual  teaching  as  in- 
ternal medicine,  and  because  of  its  peculiar  importance  should  have  a 
more  prominent  place  in  the  medical  curriculum  than  is  usually  as- 
signed it.  Obstetrics  presents  special  difficulties  because  of  the  infre- 
quence  of  maternity  wards  and  also  on  account  of  the  wide  scattering 
of  the  out-patient  service,  but  these  difficulties  are  not  insurmountable. 

Surgery,  from  the  point  of  view  of  diagnosis  and  the  care  and  treat- 
ment of  the  minor  common  lesions  and  injuries,  may  be  taught  by  the 
same  methods  as  those  outlined  for  internal  medicine,  and,  most  im- 
portant of  all,  the  frequent  lectures  and  large  operative  clinics  from 
which  the  students  gain  little  or  nothing,  should  be  replaced  by  courses 
in  experimental  and  veterinary  surgery,  ofEering  an  opportunity  for  de- 
tailed training  in  the  administration  of  anesthetics,  in  asepsis  and  anti- 
sepsis, in  the  preparation  before  and  the  care  after  operation,  and  above 
all  for  the  study  of  repair  of  wounds  and  their  treatment. 

Much  of  surgery  and  of  the  various  specialties  should  be  given  as 
elective  courses,  in  the  manner  adopted  by  this  school,  or  as  postgradu- 
ate work.  No  physician  needs  to  know,  or  can  know,  all  the  specialtie' 
in  detail,  and  only  a  relatively  small  number  become  operating  sur- 
geons. Those  that  do  specialize,  do  so  only  after  a  thorough  postgradu- 
ate training.    The  great  bulk  of  men  who  practise  medicine  should  have 


114  MEDICAL    EESEAECE    AND    EDUCATION 

as  thorough  a  training  in  internal  medicine  and  closely  allied  branches, 
such  as  pediatrics  and  neurology,  as  it  is  possible  to  give  With  this, 
in  the  obligatory  course  should  go  a  general  knowledge  of  the  principles 
of  surgical  diagnosis  and  a  certain  minimum  knowledge  of  the  special- 
ties; a  knowledge  sufficient  to  meet  emergencies  and  to  know  when  to 
seek  assistance  of  tlie  expert  in  this  or  that  specialty.  A  curriculum 
based  on  this  plan  would  free  a  large  amount  of  time  for  the  individual 
work  in  the  department  of  medicine  and  closely  related  branches. 

The  faults  of  the  present  system,  which  gives  undue  prominence  to 
surgery  and  the  specialties  at  the  expense  of  internal  medicine,  may  be 
illustrated  by  determining  in  a  curriculum  the  number  of  units  given 
to  each  subject,  on  the  basis  of  100  units  for  the  entire  four-year  course. 
Thus,  in  one  of  our  most  prominent  schools,  with  excellent  clinical  fa- 
cilities, we  find,  according  to  last  year's  catalogue,  anatomy,  surgery 
and  medicine  represented  by  18,  15.5  and  14  units,  respectively.  The 
nearest  approach  to  these  figures  is  pathology  with  9.5  units.  If  the 
units  of  the  courses  in  orthopedic  surgery,  genito-urinary  surgery  and 
surgical  anatomy  be  added  to  surgery,  the  total  for  that  subject  becomes 
18.35  units, -while  the  addition  to  medicine  of  physical  diagnosis  and 
clinical  microscopy  raises  the  units  of  this  subject  to  only  18.  Certainly 
this  proportion  overestimates  the  importance  of  anatomy  and  surgery 
in  relation  to  internal  medicine.  Other  curious  relations  seen  are 
pediatrics  with  1  unit,  while  dermatology  has  1.5;  obstetrics  3  units, 
while  gynecology  has  2,  and  neurology  2.75,  while  mental  diseases  have 
only  0.25  of  a  unit.  These  subjects  are  taught  in  large  part  by  lectures. 
The  figures  given  are  fairly  representative  of  most  schools  which  do  not 
offer  electives  and  indicate  the  ill-advised  way  in  which  the  specialties 
are  presented  to  the  student.  An  arrangement  by  which  much  of  the 
time  given  to  lectures  in  anatomy  and  surgery  and  the  specialties  could 
be  devoted  to  practical  hospital  work  in  internal  medicine  and  well-se- 
lected elective  courses  would  give  a  better  balanced  course  without  di- 
minishing the  really  valuable  work  of  each  subject. 

One  or  two  other  matters  of  importance  in  the  teaching  of  clinical 
medicine  may  be  briefly  mentioned  here.  One  of  these  is  the  advisabil- 
ity of  offering  small  groups  of  students  the  opportunity  of  studying,  as 
an  elective,  the  diseases  of  one  organ,  or  of  related  organs,  from  every 
point  of  view.  I  have  been  much  interested  in  such  a  course  given  last 
year  by  Dr.  W.  T.  Longcope  at  the  University  of  Pennsylvania  and 


THE    EXPERIMENTAL    METHOD  115 

known  as  a  course  in  "  medical  correlation."  During  one  year  a  group 
of  six  students  studied  the  diseases  of  the  heart  from  the  clinical,  the 
pathologic,  the  experimental  and  the  therapeutic  point  of  view.  All  the 
methods  of  clinical  observation  were  brought  to  bear  on  the  cases  in  the 
wards  of  the  hospital;  gross  and  microscopic  preparations  illustrating 
the  pathology  were  examined;  the  normal  physiology  of  the  heart  was 
studied  in  animals  by  the  methods  of  physical  diagnosis  and  of  graphic 
registration,  and  finally  these  were  used  also  in  the  observation  of 
lesions  produced  experimentally.  The  relation  of  various  diseases  of  the 
heart  to  diseases  of  the  lungs,  liver,  kidney  and  other  organs  and  tissues 
was  thoroughly  covered  and  the  effect  of  treatment  on  patients  in  the 
wards  and  experimentally  produced  lesions  in  animals  observed.  Of 
the  value  of  such  a  course,  even  though  it  be  given  only  to  a  small  group, 
there  can  be  no  doubt.  Its  value,  however,  lay  in  the  point  of  view 
which  Dr.  Longcope,  as  a  widely  trained  clinician,  pathologist  and  in- 
vestigator, brought  to  bear  on  the  problems  presented.  Of  similar  im- 
portance are  the  courses  in  pathologic  physiology  formerly  given  by  Dr. 
MacCallum  in  Baltimore. 

Another  matter  concerns  departments  in  the  medical  school  known 
as  research  departments  and  variously  described  as  departments  of  ex- 
perimental pathology,  experimental  medicine  or  research  medicine. 
The  title  matters  little,  but  the  plan  of  the  department  should  be  broad 
enough  to  care  for  the  problems  of  clinical  medicine,  and  for  this  rea- 
son the  word  "  medicine  "  should  appear  in  the  title  rather  than  the 
word  "  pathology."  Such  a  department  should  keep  in  close  touch  with 
the  department  of  clinical  medicine,  and  should  supplement  the  facil- 
ities of  the  various  hospital  laboratories,  but,  nevertheless,  should  also 
work  in  cooperation  with  the  fundamental  laboratory  sciences  in  order 
to  insure  a  realization  of  the  greatest  good  to  the  school.  The  head  of 
the  department  should  be  a  man  familiar  with  the  problems  of  clinical 
medicine,  trained  preferably  as  a  pathologist,  and  with  sufficient  knowl- 
edge of  the  possibilities  of  physiology  and  chemistry  to  apply  the  meth- 
ods of  these  subjects  to  clinical  problems.  I  say  preferably  a  patholo- 
gist because  the  pathologist  is  more  apt  to  combine  clinical  training 
with  a  knowledge  of  pathology,  bacteriology  and  the  principles  of  im- 
munity than  is  the  physiologist,  chemist  or  pharmacologist,  though  any 
one  of  the  latter  might  well  head  such  a  department.  Certain  it  is  that 
whatever  his  own  training  may  have  been,  the  director  should,  with  his 


116  MEDICAL   BESEAECH   AND   EDUCATION 

assistants,  be  able  to  utilize  in  the  work  of  the  department  the  methods 
of  physiology,  chemistry  and  experimental  pathology.  In  other  words, 
he  should  have  a  department  capable  of  attacking  a  problem  in  medi- 
cine from  any  or  all  sides,  including  that  of  experimental  therapeutics ; 
and  in  order  to  make  the  work  effective,  he  should  have  the  use  of  beds 
in  the  university  hospital. 

The  work  of  this  department  should  be  the  investigation  of  clinical 
problems,  and  not  of  academic  problems  of  pathology,  chemistry,  physi- 
ology, etc.  The  latter  can  still  be  carried  on  in  the  departmental  lab- 
oratories, which  have  always  followed  academic  lines,  and,  in  truth,  are 
forcing,  through  their  neglect  of  clinical  problems,  the  establishment 
of  the  type  of  department  described.  General  practitioners,  clinical  as- 
sistants in  the  school,  and  even  those  at  the  head  of  clinical  departments 
are  constantly  meeting  problems  which  demand  solution,  but  find  no 
adequate  opportunity  to  investigate  them  in  departments  as  now  con- 
stituted. Indeed,  if  not  turned  away  at  once,  they  are  sent  from  de- 
partment to  department,  seldom  finding  either  encouragement  for  work 
or  the  equipment  necessary  for  a  problem  which  has  more  than  one  tech- 
nical side.  Such  men  would  find  a  place  in  the  department  suggested 
and  would  constitute  an  enthusiastic  working  staff  which  should  be  ex- 
ceedingly productive  and  should  influence  for  good  the  clinical  teach- 
ing. Indeed,  one  might  find  such  a  department  an  important  factor  in 
the  training  of  clinical  teachers  of  the  investigative  type. 

Another  function  of  this  department  should  be  undergraduate  in- 
struction to  fourth-year  men  taking  research  work  in  clinical  medicine 
as  an  elective,  and  also  post-graduate  instruction  for  those  desiring 
training  in  the  methods  of  experimental  medicine  as  the  basis  for  a 
career  as  teacher  or  investigator. 

I  may  be  over-enthusiastic  about  this  matter,  but  I  believe  that  de- 
partments such  as  I  have  outlined  are  a  necessary  part  of  every  large 
university  medical  school,  and  must  be  developed  eventually  through 
the  combined  efforts  of  the  pathologist  and  the  clinician,  who  have  nat- 
urally a  greater  interest  in  the  problems  of  disease  than  have  the  men 
of  other  departments  and  who  must  have  an  investigative  department 
devoted  to  their  common  interests. 

In  this  discussion  I  have  approached  the  subject  from  the  side  of 
the  teacher,  and  if  I  have  emphasized  the  faults  of  our  system  it  is 
because,  as  you  have  probably  surmised,  I  have  desired  to  point  out 


TEE    EXFEBIMENTAL   METHOD  117 

what  is  best  for  the  student  in  that  training  which  leads  to  the  practise 
of  medicine.  The  practise  of  medicine  has  developed  out  of  empiricism 
by  the  application  of  the  methods  of  its  tributary  sciences  and  whatever 
is  definitely  known  and  understood  in  medicine  can  be  traced  to  the 
application  of  the  experimental  method.  You,  therefore,  as  students 
of  medicine,  must  consider  the  fundamental  medical  sciences,  not  as  a 
mere  accumulation  of  facts,  but  as  an  opportunity  for  training  in 
principles  and  methods  which  you  can  apply  to  the  specific  problems 
of  clinical  medicine,  and  then  later,  when  your  days  as  student  and 
interne  are  over,  you  should,  if  you  follow  this  course,  have  acquired  a 
power  in  the  use  of  the  methods  of  experimental  medicine  which  will 
be  of  value  to  you  in  your  every-day  work.  You  will  have  an  interest 
not  only  in  the  investigation  of  the  problems  of  general  practise  by  the 
usual  clinical  methods,  but  you  will  find  yourself  turning  to  the  meth- 
ods of  the  laboratory,  and  this  may  result  not  only  to  your  own  advan- 
tage, but  to  the  advantage  of  the  science  of  medicine  in  general.  In 
brief,  you  will  be  doing  your  share  to  establish  a  science  of  clinical 
medicine  on  which  only  can  the  practise  of  medicine  be  properly  based. 
That  such  activities  on  the  part  of  the  clinician  are  now  generally 
recognized  as  desirable  is  shown  very  clearly  by  the  formation  of  new 
societies  to  encourage  and  promote  clinical  research.  The  Association 
for  the  Advancement  of  Clinical  Investigation,  for  example,  has  brought 
together  a  large  group  of  men,  mainly  of  the  younger  set,  interested 
in  investigation  in  internal  medicine.  Likewise,  the  Interurban 
Clinical  Club  has  stimulated,  as  will  doubtless  its  junior  counterpart 
now  being  organized,  an  interest  in  exact  investigation  in  medicine 
which  is  prophetic  of  a  great  change  not  only  in  the  practise  of  medi- 
cine, but  in  our  methods  of  teaching.  I  can  wish  each  of  you  no 
greater  honor  than  membership  in  the  Association  for  the  Advance- 
ment of  Clinical  Investigation. 

In  recommending  to  you  that,  as  practitioners,  you  keep  always 
the  point  of  view  of  the  investigator,  I  realize  fully  that  as  you  go  out 
among  so-called  "  practical "  doctors  you  will  find  many  who  sneer  at 
what  they  term  the  "  scientific  "  doctor.  This  view,  of  which  we  hear 
less  and  less  each  year,  is  a  survival  of  the  opinion  commonly  held 
prior  to  the  development  of  the  sciences  of  bacteriology  and  physiologic 
chemistry,  which  sciences,  by  their  practical  applications  to  every-day 
medicine,  have  perhaps  done  more  to  dispel  it  than  is  usually  realized. 


118  MEDICAL   BESEABCH   AND    EDUCATION 

I  may  quote  from  the  words  of  a  past  and  present  teacher  in  this  school 
to  illustrate  this  change  in  attitude.  Fortunately,  for  purposes  of 
comparison,  both  represent  the  department  of  anatomy.  One,  Oliver 
Wendell  Holmes,  in  an  introductory  lecture  to  the  class  of  1867,  dis- 
cussed the  question  of  whether  or  not  the  young  physician  should  take 
an  active  interest  in  investigation  in  medicine.  He  expressed  his  dis- 
approval in  the  words  "  take  down  your  sign,  or  never  put  it  up,"  thus 
implying  that  at  that  time  practise  and  investigation  were  considered 
incompatible.  The  same  implication  we  find,  also,  in  his  frequently 
quoted  phrase,  if  a  man  "  has  not  plenty  of  good  common  sense,  the 
more  science  he  has,  the  worse  for  the  patient."  Thirty  years  later, 
we  find  your  present  professor  of  comparative  anatomy  summing  the 
matter  up  in  the  statement :  "  So  far  as  I  know,  the  most  important 
difference  between  a  '  practical '  doctor  and  the  truly  scientific  is  that 
the  patients  of  the  former  are  more  likely  to  die." 

You  may  not  be  aware  of  it,  but  this  change  in  attitude,  as  seen 
not  only  in  this  school,  but  throughout  the  country,  may  be  traced  to 
the  efforts  of  one  man,  the  late  Henry  Pickering  Bowditch,  who,  by 
establishing  in  the  seventies  a  modern  laboratory  of  physiology  at 
Harvard,  initiated  those  facilities  for  instruction  and  research  on  which 
our  present  standards  rest.  By  his  own  work,  in  his  laboratory  and 
out  of  it,  by  printed  and  spoken  word,  by  suggestion  and  kindly  criti- 
■cism,  he  labored  for  one  ideal  in  medicine,  the  training  of  the  scientific 
physician.  Indeed,  I  do  not  think  it  an  exaggeration  to  say  that  these 
magnificently  equipped  buildings  in  which  you  are  receiving  your 
medical  training  are  the  culmination  of  this  ideal.  Dr.  Bowditch 
believed  in  the  scientific  rather  than  the  so-called  "  practical "  physi- 
cian, and  to  this  belief,  to  his  labors  and  his  influence,  is  due  the  most 
valuable  part  of  the  education  you  are  now  receiving.  You  owe  him, 
as  does  this  school,  and  as  does  also  the  entire  medical  profession  and 
the  cause  of  medical  education  in  America,  a  great  debt ;  this  in  so  far 
as  it  concerns  you,  you  can  repay,  in  part,  at  least,  by  so  utilizing  your 
training  as  to  advance  the  cause  of  scientific  medicine  and  thus  con- 
tinue the  good  work  which  Dr.  Bowditch  began.  Memorials  he  will 
have  in  abundance;  this  school  in  the  fulfilment  of  his  conception  of 
its  development  the  greatest  of  them  all,  but  I  am  sure  no  tribute 
would  please  him  more  than  that  offered  by  its  graduates  in  an  earnest 
desire  to  make  real  his  vision  of  the  scientifically  trained  physician. 


TRE    EXPEBIMENTAL    METHOD  119 

As  to  the  views  which  I  have  exj^ressed,  I  wish  to  make  it  clear 
that  I  do  not  refer  to  the  training  of  the  investigator,  be  he  physician 
or  otherwise,  usually  described  as  a  genius.  My  suggestions  are  offered 
as  a  possible  means  of  adding  to  the  number  of  those  individuals,  of 
whom  we  still  have  too  few,  who,  slowly,  steadily  and  safely  advance 
established  lines  of  research  or  of  practise  by  adding  a  little  here  and 
strengthening  a  little  there  in  the  gradual  change  from  an  empiric  to 
a  scientific  medicine. 

Moreover,  I  claim  no  great  originality,  but  present  my  conclusions 
as  a  fairly  accurate  statement  of  the  results  of  a  close  study  of  our 
methods  of  teaching,  and  if  I  have  magnified  the  faults  of  our  system, 
it  is  not  from  a  desire  to  be  hypercritical,  but  with  the  hope  that  closer 
attention  to  such  faults  may  hasten  improvement. 

I  have  read  recently  an  address  by  President  MacLaurin  in  which 
he  discusses  some  of  the  factors  which  in  the  course  of  fifty  years  have 
placed  the  Massachusetts  Institute  of  Technology  in  its  present  com- 
manding position.  Two  of  these  factors  are  worthy  of  the  earnest 
consideration  of  the  trustees  and  teachers  of  our  medical  schools. 
The  first  President  MacLaurin  presents  as  follows :  "  There  has  never 
been  any  uncertainty  or  indefiniteness  as  to  what  the  institute  is  aiming 
at  in  its  scheme  of  education  " ;  the  second  embodies  the  idea  that  the 
success  of  the  educational  policy  of  the  institute  has  been  due  to  the 
fact  that  the  emphasis  has  been  laid  on  the  "  method  "  and  s-pxr'it  of 
science  rather  than  on  subject,  and  that  the  ""  method  hy  doing  "  or 
"do  it  yourself"  idea  has  been  systematically  applied.  "We  need,  in 
medicine,  a  greater  appreciation  of  both  these  factors  by  our  trustees 
as  well  as  by  our  teachers;  of  educational  policy  by  the  former,  of 
educational  method  by  the  latter. 

Eeferences 

The  following  list  of  addresses  is  appended  as  representing  some  of  the 
arguments  in  favor  of  the  use  of  the  experimental  method  in  the  teaching  of 
medicine.  I  freely  acknowledge  the  use  of  much  of  the  material  and  many  of 
the  suggestions  therein  contained. 

Barker,  L.  F. :  "Medical  Laboratories;  Their  Eelation  to  Medical  Practise  and 

to  Medical  Discovery,"  Science,  1908,  XXVII.,  601. 
Barker,  L.  F. :   "  The  Organization  of  the  Laboratories  in  the  Medical  Clinic 

of    the    Johns    Hopkins    Hospital,"    Bull.    Johns    Hopkins    Hosp.,    1907, 

XVIII.,  193. 
Blumer,  C. :    "  Equipment  and  Instruction  of  the   Clinical  Years, ' '  Am.  Med. 

Assoc.  Bull.,  1911,  VI.,  97. 


120  MEDICAL   BESEABCH   AND   EDUCATION 

Bowditch,  H.  P. :  "  The  Medical  School  of  the  Future, ' '  Boston  Med.  and  Surg. 

Jour.,  May  3,  1900. 
Burr,  C.  W.:  "Medical  Education,"  PUla.  Med.  Jour.,  October  21,  1899. 
Cabot,  R.  C,  and  Locke,  E.  A. :  "  The  Organization  of  a  Department  of  Clinical 

Medicine,"  Boston  Med.  and  Surg.  Jour.,  October  26,  1905. 
Chiari,  H. :  "  Ueber  den  Unterricht  in  der  Pathologic  in  den  Vereinigten  Staaten 

von  Nordamerika, "  MuncJien  med.  Wochenschr.,  1911,  LVIIL,  260. 
Dodson,  J.  M. :   "The  Research  Idea  and  Methods  in  Medical  Education  and 

Practise,"  Jour.  Amer.  Med.  Assoc,  July  8,  1905,  p.  81. 
Eliot,  C.  W.:  "The  Future  of  Medicine,"  Science,  1906,  XXIV.,  449. 
Ferguson,  J.   S. :   "The  Teaching  of  Visceral  Anatomy  or  Organology,"  Jour. 

Amer.  Med.  Assoc,  1911,  LVI.,  1544. 
Flexner,  A.:   "Medical  Education  in  the  United  States  and  Canada,"  Bull.  4 

Carnegie  Foundation  for  the  Advancement  of  Teaching. 
Herrick,   J.   B. :    "The   Educational   Functions   of   Hospitals   and   the   Hospital 

Year,"  Am.  Med.  Assoc.  Bull.,  1911,  VI.,  105. 
Herter,   C.   A.:    "Imagination  and  Idealism   in   the  Medical   Sciences,"   Jour. 

Amer.  Med.  Assoc,  February  5,  1910,  LIV.,  423. 
Jesse,  R.  H. :  "Teaching  Medicine  Aright,"  Jour.  Mo.  State  Med.  Assoc,  1911, 

VII.,  331. 
Lyon,  E.   P.:    "Equipment  and  Instruction   of   the   Laboratory   Years,"   Am. 

Med.  Assoc  Bull,  1911,  VI.,  88. 
MacCallum,    W.    G.:    "On    the    Teaching    of    Pathological    Physiology,"    Bull. 

Johns  HopJcins  Eosp.,  1906,  XVII.,  251:  1907,  XVIII.,  327;  1908,  XIX., 

215. 
Meltzer,  S.  J.:   "The  Science  of  Clinical  Medicine,"  Jour.  Amer.  Med.  Assoc, 

August  14,  1909,  p.  508. 
Minot,  C.  S.:  "Knowledge  and  Practise,"  Science,  1899,  X.,  1. 
Minot,  C.  S. :  "Certain  Ideals  of  Medical  Education,"  Jour.  Amer.  Med.  Assoc, 

August  14,  1909,  p.  502. 
Minot,  C.  S.:  "The  Method  of  Science,"  Science,  1911,  XXXIIL,  119. 
Taylor,  A.  E. :  "The  Dynamic  Point  of  View  in  Pathology,"  Proc  Path.  Sac. 

Phil,  1907,  p.  29. 
Welch,    W.    H.:    "The    Relation    of    the    Hospital    to    Medical    Education    and 

Research,"  Jour.  Amer.  Med.  Assoc,  August  17,  1907,  p.  531. 


CHANCE  AND  THE  PREPARED  MIND^ 

By  Richard  M.  Peakce,  M.D., 
Professor  of  Research  Medicine,  Univeesity  op  Pennsylvania 

"In  the  fields  of  observation  chance  favors  only  the  mind  which  is  pre- 
pared. ' ' — Pasteur. 

It  was  at  the  opening  of  the  Faculte  des  Sciences  at  Lille  on 
December  1,  1854,  that  Pasteur,  only  thirty-two  years  of  age  at  the 
time,  but  already  professor  and  dean  of  the  faculty,  uttered  these  words 
in  upholding,  in  his  inaugural  address,  the  value,  on  the  one  hand,  of 
practical  laboratory  instruction  as  an  aid  to  the  solution  of  industrial 
problems,  and,  on  the  other,  the  importance  of  investigation  in  pure 
science,  even  though  the  resulting  discoveries  might  have  no  immediate 
application.  The  point  of  view  may  have  been  novel  when  it  was 
uttered,  but  in  the  sixty  years  that  have  elapsed  how  familiar  it  has 
become.  How  closely  it  approximates  the  ideals  of  those  who  are 
striving  to  improve  the  conditions  of  medical  education  and  of  medical 
research  in  our  own  day  and  country.  "What  better  argument  can  the 
most  ardent  advocate  of  detailed  practical  instruction  in  laboratory  or 
hospital  (medical  training  at  first  hand)  present,  than  that  which 
Pasteur  offered  in  1854.     He  asks: 

Where  will  you  find  a  young  man  whose  curiosity  and  interest  will  not 
immediately  be  awakened  when  you  put  into  his  hands  a  potato,  when  with  that 
potato  he  may  produce  sugar,  with  that  sugar,  alcohol,  with  that  alcohol,  aether 
and  vinegar?  Where  is  he  that  will  not  be  happy  to  tell  his  family  in  the 
evening  that  he  has  just  been  working  out  an  electric  telegraph?  And,  gentle- 
men, be  convinced  of  this,  such  studies  are  seldom,  if  ever,  forgotten.  It  is  some- 
what as  if  geography  were  to  be  taught  by  traveling;  such  geography  is  remem- 
bered because  one  has  seen  the  places.  In  the  same  way  your  sons  will  not 
forget  what  the  air  we  breathe  contains  when  they  have  once  analyzed  it,  when 
in  their  hands  and  under  their  eyes  the  admirable  properties  of  its  elements 
have  been  resolved." 

*  An  address  given  under  the  auspices  of  the  Alpha  Omega  Alpha  Honorary 
Medical  Fraternity,  Syracuse  University.     Published  in  Science,  June  21,  1912. 

"  Vallery-Radot,  "The  Life  of  Pasteur,"  McClure,  Phillips  &  Co.,  New 
York,  1902. 

121 


122  MEDICAL   BE  SEARCH   AND    EDUCATION 

Pasteur  was  a  chemist,  a  physical  chemist,  if  you  will,  and  his 
illustrations  were  drawn  from  the  realms  of  physics  and  chemistry, 
but  if  one  substitutes  for  "  electric  telegraph  "  any  piece  of  apparatus 
now  in  use  in  a  medical  laboratory  or  a  hospital,  the  principle  of  the 
better  type  of  modern  medical  instruction  is  embodied  in  his  argument. 
He  was  talking  to  those  who,  after  two  years  of  practical  and  theoretical 
study,  were  to  enter  industrial  careers  as  overseers  and  foremen  in 
factories,  foundries  and  distilleries.  But  neither  time  nor  circum- 
stance fundamentally  alters  the  applicableness  of  his  observations. 
After  sixty  years  we  may  still  urge  his  thought  as  the  soundest  of  prin- 
ciples in  the  better  education  of  men  and  women  who  are  ultimately 
intended  to  enter  careers  as  our  overseers  in  matters  of  health  and 
disease  and  as  the  foremen  of  public  hygiene.  Have  our  present-day 
medical  schools  succeeded  in  bringing  to  the  training  of  their  students 
the  same  practical  and  scientific  thoroughness  which  Pasteur  demanded 
for  students  in  the  industrial  sciences  and  which  students  of  the  latter 
sciences  now  procure?  If  not,  where  lies  the  fault;  in  the  college  or 
the  medical  school,  in  the  state  or  the  public?  Or  are  all  more  or  less 
to  blame?  These  questions  will  be  discussed  in  due  time,  but  first 
let  us  turn  to  Pasteur's  other  proposition,  investigation  for  its  own 
sake.  After  stating  his  wish  to  be  directly  useful,  personally  and 
through  his  laboratory,  to  the  industries  of  Lille,  he  says: 

Without  theory,  practise  is  but  routine  borne  of  habit.  Theory  alone  can 
bring  forth  and  develop  the  spirit  of  invention.  It  is  to  you  specially  that  it 
will  belong  not  to  share  the  opinion  of  those  narrow  minds  who  disdain  every- 
thing in  science  which  has  not  immediate  application.  You  know  Franklin's 
charming  saying?  He  was  witnessing  the  first  demonstration  of  a  purely 
scientific  discovery,  and  people  round  him  said:  "But  what  is  the  use  of  it?" 
Franklin  answered  them:  "What  is  the  use  of  a  new-born  child?" 

Do  you  know  when  this  electric  telegraph,  one  of  the  most  marvelous  appli- 
cations of  modern  science,  first  saw  the  light?  It  was  in  the  memorable  year 
1822;  Oersted,  a  Danish  physicist,  held  in  his  hands  a  piece  of  copper  wire, 
joined  by  its  extremities  to  the  two  poles  of  a  Volta  pile.  On  his  table  was  a 
magnetized  needle  on  its  pivot,  and  he  suddenly  saw  (by  chance  you  will  say, 
but  chance  favors  only  the  mind  which  is  prepared)  the  needle  move  and  take 
up  a  position  quite  different  from  the  one  assigned  to  it  by  terrestrial  magnetism. 
A  wire  carrying  an  electric  current  deviated  a  magnetized  needle  from  its 
position!  That,  gentlemen,  was  the  birth  of  the  modem  telegraph.  Franklin's 
interlocutor  might  well  have  said  when  the  needle  moved:  "But  what  is  the  use 
of  that  ? ' '  And  yet  that  discovery  was  barely  twenty  years  old  when  it  produced 
by  its  application  the  almost  supernatural  effects  of  the  electric  telegraph! 


CHANCE    AND    TEE    PEE  PA  BED    MIND  123 

This,  gentlemen,  may  seem  trite  to  you,  for  it  is  an  argument  oft 
repeated,  but  its  significance,  as  far  as  medicine  is  concerned,  lies  in 
the  fact  that  at  the  time  Pasteur  made  these  statements  modern  medical 
investigation  was  just  beginning.  The  celebrated  physiological  insti- 
tute at  Berlin  had  been  in  existence  only  sixteen  years;  Schwann,  fol- 
lowing Schleiden,  had  elaborated  the  cell  doctrine  only  fifteen  years 
before  and  anesthesia  had  been  practised  for  only  six  years.  Claude 
Bernard  was  in  the  midst  (1850-60)  of  his  important  discoveries 
concerning  the  pancreatic  juice,  the  glycogenic  function  of  the  liver 
and  the  vasomotor  system;  three  years  were  to  pass  before  Yirchow 
established  (1855)  the  first  pathological  institute  and  as  many  again 
before  this  great  master  was  to  announce  the  doctrine  of  cellular 
pathology;  and  finally,  it  was  thirteen  years  before  Lister's  first  pub- 
lication concerning  the  antiseptic  treatment  of  wounds. 

In  all  these  activities  and  those  which  followed,  the  ideal  of  seeking 
for  the  truth  no  matter  where  it  might  lead — the  ideal  of  pure  science 
— was  the  secret  of  that  wonderful  progress  which  medicine  has  made 
in  the  last  seventy-five  years. 

Xow,  however,  it  is  time  to  return  to  our  text,  "  In  the  fields  of 
observation,  chance  favors  only  the  mind  which  is  prepared."  What 
did  Pasteur  mean  by  "  chance  "  ?  His  meaning  is  very  evident  in  his 
example  of  Oersted  and  the  magnetized  needle.  The  mind  which  is 
trained  to  observe  the  details  of  natural  phenomena,  and  to  reason  con- 
cerning the  bearing  of  known  laws  on  such  phenomena,  is  the  "  pre- 
pared mind,"  that  is  to  say,  it  is  a  class  of  mind  which,  because  it  is 
endowed  with  a  peculiar  faculty,  best  described  as  scientific  imagination 
— grasps  the  significance  of  a  new  observation,  or  of  a  variation  from  a 
known  sequence  of  events,  and  thus  establishes  a  new  law  or  invents  a 
new  practical  procedure.  To  no  man  perhaps  is  this  adage  of  Pasteur 
more  applicable  than  to  himself.  It  was  his  work  in  chemistry  and 
his  studies  in  crystallography  that  gave  him  the  "  prepared  mind " 
which  correctly  interpreted  the  significance  of  the  chance  observation 
that  the  presence  of  a  vegetable  mould,  the  Penicilium  glaucum,  in 
solutions  of  salts  of  the  tartaric  acids,  changed  an  optically  inactive  to 
an  optically  active  fluid.  He  grasped  at  once  the  true  interpretation 
of  this  reaction.  The  disappearance  of  the  dextro-tartaric  acid,  the 
permanence  of  the  levo-tartaric  acid,  could  be  explained  only  by  the 
assumption  that  the  ferments  of  this  particular  fermentation  "  feed 


124  MEDICAL   RESEABCH   AND   EDUCATION 

more  readily  on  the  right  than  on  the  left  molecules."  So  did 
"  chance  "  direct  the  "  prepared  mind  "  to  those  fundamental  observa- 
tions which  established  our  present-day  principles  of  fermentation,  and 
which,  as  the  result  of  work  on  alcoholic,  acetic,  lactic  and  butyric 
fermentation,  led  to  Pasteur's  final  dictum : 

The  chemical  act  of  fermentation  is  essentially  a  correlative  phenomenon  of 
a  vital  act  beginning  and  ending  with  it. 

It  was  but  a  short  step  for  the  mind  thoroughly  familiar  with  the 
principles  of  fermentation  to  embrace  the  opportunity  offered  by  the 
study  of  the  etiology  of  the  infectious  diseases,  and  so  through  all  his 
work,  as  that  in  connection  with  the  silk-worm  problem,  vaccination 
against  chicken  cholera  and  anthrax,  and  the  treatment  of  rabies,  the 
"  prepared  mind  "  of  the  great  master  saw  and  appreciated  the  signifi- 
cance of  every  observation  and  every  opportunity  which  presented  itself. 

Many  other  examples  might  be  presented,  as  Semmelweis  and  his 
observations  on  the  high  mortality  from  puerperal  sepsis  among  those 
under  the  care  of  students  fresh  from  the  dissecting  and  autopsy  room 
and  the  low  mortality  among  patients  under  other  supervision.  So  also 
Lister  and  his  antisepsis;  and  best  of  all,  perhaps,  for  purposes  of 
illustration,  the  sequence  of  Ehrlich's  discoveries.  We  are  told  that  in 
his  student  days  Ehrlich  was  interested  above  all  other  things  in  the 
study  of  chemical  affinities  and  worked  incessantly  with  the  new  anilin 
dyes.  Indeed  the  story  goes  that  so  engrossed  was  Ehrlich  in  his  work 
that  neglect  of  the  required  studies  gave  rise  to  some  question  concern- 
ing his  right  to  receive  his  degree.  The  situation  as  described  by 
Christian  A.  Herter^  was  as  follows: 

Although  at  this  time  Ehrlich  was  especially  under  the  direction  of  the 
anatomist  Waldeyer,  he  rapidly  developed  a  capacity  for  chemistry  which  was 
a  surprise  both  to  himself  and  to  the  chemist,  Adolf  von  Baeyer,  whose  lectures 
had  been  systematically  cut  by  the  gifted  but  unconventional  student.  For 
unconventional  he  then  was,  and  ever  has  been,  neglecting  what  he  did  not  like 
and  throwing  himself  with  fervor  and  intense  energy  into  the  solution  of  the 
themes  that  attracted  him.  From  the  outset  it  was  clear  that  Ehrlich  would 
make  a  career  as  an  experimental  investigator.  Much  of  the  time  he  was  sup- 
posed to  spend  in  taking  the  usual  medical  courses  he  devoted  to  experiment. 
When  Eobert  Koch  was  shown  through  the  laboratory  at  Breslau  by  one  of  the 
professors,  his  attention  was  called  to  a  young  student  working  at  a  desk  covered 
with  bottles  of  dyestuffs.  ' '  There  is  our  little  Ehrlich, ' '  said  the  professor ; 
"he  is  a  first-rate  stainer  of  tissues,  but  he  will  never  pass  his  examinations. ' ' 

^  Herter,  C.  A.,  "Imagination  and  Idealism  in  the  Medical  Sciences,"  Jour. 
Am.  Med.  Assoc,  LIV.,  p.  423,  1910. 


CHANCE   AND    THE    PEEPAEED   MIND  125 

The  prediction  about  the  examinations  came  perilously  near  fulfillment;  Ehrlich 
made  bad  flunks  and  it  is  hinted  that  he  never  would  have  received  his  degree 
had  he  not  made  a  discovery — namely,  the  existence  of  the  peculiar  type  of 
leucocyte  which  is  known  to  us  as  the  "plasma-cell."  The  faculty  reasoned 
that  it  would  be  improper  to  keep  so  promising  and  original  a  worker  indefinitely 
in  an  undergraduate  position,  and  it  is  suspected  that  they  mitigated  the  rigor 
of  the  examinations  in  order  to  relieve  their  o^vn  embarrassment. 

These  early  studies  were  doubtless  responsible  for  what  must  be 
considered  as  the  main  theme  of  all  Ehrlich's  work — the  specific  affinity 
which  exists  between  specific  living  cells  and  specific  chemical  sub- 
stances. The  "  prepared  mind  "  is  evident  in  his  study  of  the  cells  of 
the  blood,  of  the  selective  action  of  methylene  blue  on  the  nervous 
system,  of  the  use  of  the  same  dye  in  the  study  of  oxidations  and  reduc- 
tions occurring  in  tissues,  of  his  studies  in  immunity,  of  the  specific 
treatment  of  protozoan  disease,  and  also  according  to  recent  reports  in 
his  application  of  the  same  principle  to  the  study  of  cancer.  Manson's 
studies  of  the  relation  of  the  mosquito  to  filariasis,  which  led  to  Eoss's 
study  of  the  transmission  of  malaria  by  the  same  insect,  is  another 
example  of  the  "  prepared  mind "  properly  interpreting  a  chance 
observation.  Sometimes  such  discoveries  are  referred  to  as  the  result 
of  scientific  imagination — and  it  truly  is  this — but  doubtless  the  same 
"  chance "  came  to  many  besides  Pasteur,  Ehrlich,  I^averan,  Koch, 
Theobald  Smith,  Manson,  Eoss  and  Eeed;  it  was  the  training  of  these 
individuals,  the  mind  prepared  to  utilize  scientific  imagination,  that 
enabled  them  to  grasp  the  opportunity  offered  by  "  chance  "  observa- 
tion. Every  one  familiar  with  the  history  of  investigation  in  medicine 
knows  that  before  Harvey,  men  studied  the  circulation;  that  before 
Pasteur,  bacteria  were  seen  in  diseased  conditions;  before  Lister,  the 
effect  of  cleanliness  upon  surgical  mortality  had  been  noticed;  before 
Laveran,  the  plasmodium  of  malaria  had  been  seen ;  before  Manson  and 
Eoss,  the  possibility  of  the  transmission  of  malaria  by  the  mosquito 
had  been  discussed.     Truly, 

remarkable  achievements  are  never  unique  occurrences  in  nature.  Even  the 
greatest  men  rest  on  the  shoulders  of  a  large  multitude  of  smaller  ones  who  have 
preceded  them,  and  epochal  discoveries  emerge  out  of  a  period  of  intellectual 
restlessness  that  affects  many  minds.' 

But  of  these  minds,  it  is  that  one  which  is  "  prepared,"  trained  in 
the  methods  of  observation,  therefore  possessing  the  priceless  quality  of 

'Flexner,  S.,  "The  Biological  Basis  of  Specific  Therapy,"  Ether  Day 
address  at  the  Massachusetts  General  Hospital,  October  16,  1911. 


126  MEDICAL   BESEABCH   AND   EDUCATION 

scientific  imagination,  which  sees  the  proper  block  which  when  placed 
exactly  where  it  belongs  completes  the  edifice  of  a  perfect  theory,  and 
thus  establishes  a  new  landmark  for  future  progress. 

But  what,  you  ask,  has  all  this  to  do  witlilhe  training  of  the  physi- 
cian ?  How  does  it  apply  to  medical  education  ?  We  admit  the  value 
of  these  qualities  in  the  investigator,  but  of  what  value  are  they  to  the 
man  seeking  the  education  necessary  to  practise  medicine?  Let  me 
repeat  Pasteur's  adage — "  In  the  fields  of  observation,  chance  favors 
only  the  mind  which  is  prepared."  Certainly,  all  will  agree  that  medi- 
cine is  largely  an  observational  science  and  one  of  the  "  fields  of 
observation  "  of  Pasteur's  definition.  Medicine  may  not  be  all  science, 
but  clinical  medicine  in  its  most  essential  phase — diagnosis — is  essen- 
tially a  science  of  observation,  either  of  direct  observation  by  the  use 
of  the  unaided  senses  or  indirect  by  the  use  of  instruments  of  precision, 
or  by  chemical,  biological  or  other  tests.  Therefore,  whatever  force  or 
whatever  lesson  this  adage  may  carry  applies  to  medicine.  And  now 
as  to  the  interpretation  of  "  chance."  I  have  not  been  able  to  obtain 
the  original  French  of  Pasteur,  but  from  his  parenthetical  phrase  in 
connection  with  the  discussion  of  the  telegraph  it  is  clear  that  he 
meant  exactly  what  the  translator  has  given  us,  chance  or  opportunity 
in  the  sense  of  an  unexpected  observation  or  an  accidental  occurrence, 
Pasteur's  idea  was  that  such  unexpected  or  accidental  occurrences 
would  not  arrest  the  attention  of  the  poorly  prepared  mind,  but  that 
the  well-prepared  mind,  trained  to  observe,  to  think  and  to  compare, 
would  grasp  the  significance  of  the  unexpected,  the  unusual  or  occa- 
sional, put  the  observation  to  the  test,  by  experiment  or  control,  and 
arrive  at  the  correct  conclusion.  Is  not  this  a  matter  of  daily  occur- 
rence in  clinical  medicine?  Does  not  chance  (opportunity  some  would 
call  it)  and  care  in  details  play  an  important  part  in  diagnosis?  Is  not 
every  ailment  the  physician  sees  a  puzzle?  every  diagnosis,  if  correct, 
a  solution  of  that  puzzle  ?  One  speaks  of  the  man  who  solves  the  puzzle 
which  has  baffled  half  a  dozen  other  men  as  a  keen  or  accurate  diag- 
nostician. They  imply  that  he  has  an  added  power,  or  that  his  skill 
is  the  result  of  wider  experience,  forgetting  they  may  have  seen  as  many 
individuals  with  the  malady  as  had  the  consultant,  and  perhaps  totally 
ignorant  of  the  fact  that  his  diagnosis  was  possibly  based  on  a  chance 
observation  which  meant  more  to  his  trained  imagination  than  it  did 
to  minds  unaccustomed  to  weigh  the  significance  of  details.      Every 


CHANCE   AND    THE    PBEPASED   MIND  127 

clinician  of  experience  can  give  examples  of  the  importance  of  chance 
and  imagination  in  actual  diagnosis.     An  interesting  illustration  is  that 

of  the  two  students  who  reported  on  the  same  patient  in  competition  for  a 
clinical  prize.  The  patient  presented,  among  other  symptoms,  a  remarkable 
discoloration  of  a  certain  area  of  skin,  and  the  first  student  described  this 
discoloration  with  the  most  careful  minuteness.  He  measured  it  in  different 
directions  and  drew  a  rough  sketch  of  its  general  outline.  The  second  observed 
the  phenomenon  with  equal  care,  but  he  exercised  his  imagination  and  formed 
a  hypothesis  which  he  proceeded  to  put  to  the  test.  He  asked  a  nurse  for  a 
wet  towel,  with  which  he  wiped  the  discoloration  away.  It  is  evident  that  the 
faculty  which  he  thus  brought  to  bear  on  the  problem  before  him  would  be 
likely  to  stand  him  in  good  stead  in  relation  to  many  others  of  a  more  compli- 
cated character;  and  that  his  exercise  of  the  art  of  diagnosis  would  be  practically 
immune  from  the  errors  incidental  to  the  habit  of  taking  all  appearances  at  their 
face  value.  Imagination  at  once  points  to  the  possibility  of  more  than  one 
explanation  of  any  given  occurrence,  or  alleged  occurrence,  and  compels  inquiry 
as  to  the  existence  of  probable  causes  beyond  the  particular  one  which  may  at 
first  sight  appear  to  have  been  in  operation.* 

From  what  has  been  said,  then,  it  should  be  evident  that  it  is  the 
first  duty  of  a  medical  school  to  prepare  men  properly  for  the  practise 
of  medicine  (and  the  most  ardent  advocate  of  research  in  the  university 
will  not  deny  that  this  is  the  first  duty).  If  so,  what  are  the  conditions 
to  be  fulfilled  to  ensure  the  "  prepared  mind  "  of  Pasteur's  adage  ? 

The  Preliminary  Education^  of  the  indivdual  is  the  first  and  in 
many  ways  the  most  important  consideration.  I  know  it  is  bringing 
coals  to  Newcastle  to  discuss  this  question  before  the  students  and 
faculty  of  Syracuse  University,  for  you  have  been  among  the  first  to 
recognize  the  value  of  two  years'  college  work  which  shall  include 
physics,  chemistry  and  biology.  Still  this  principle  is  not  generally 
recognized.  Many  of  those  in  positions  of  authority  in  our  medical 
schools,  while  loudly  proclaiming  the  right  of  medicine  to  a  place 
among  the  sciences  and  indeed  characterizing  it  as  the  "  Mother  of  the 
Sciences,"  deny  that  a  scientific  education  is  a  prerequisite  to  medicine. 
True,  the  opposition  is  frequently  due  to  a  realization  of  the  awkward 
financial  position  in  which  an  administration  might  be  placed  if  stu- 
dents' fees  diminished.  Frequently  also  it  is  due  to  the  claims  of 
those  who  hold  that  a  greater  cultural  value  lies  in  following  the 
humanistic  rather  than  the  scientific  school  of  thought.  Naturally, 
there  is  also  the  "poor  boy  cry"  and  the  closely  associated  cry  that 
outlying  districts  will  not  be  properly  cared  for  if  the  cost  of  medical 

*"  Imagination  in  Medical  Eesearch,"  Lancet,  1912,  CLXXXII.,  179. 


128  MEDICAL   BESEABCH    AND    EDUCATION 

education  is  increased.  The  "  poor  boy  "  argument  may  be  dismissed 
at  once,  for  those  who  have  had  experience  in  teaching  medicine  know- 
that  the  boy,  poor  or  otherwise,  who  knows  what  he  wants  in  the  way 
of  an  education,  gets  that  education  in  spite  of  all  difficulties,  and  as 
a  rule,  if  he  has  to  work  for  it,  is  keen  enough  to  get  the  best  that  is 
to  be  had.  Such  men  will  "  come  through  "  despite  all  apparent  bar- 
riers in  the  way  of  higher  preliminary  requirements;  if  the  indifferent 
"  poor  boy  "  fails,  lacking  ambition  and  a  clear  conception  of  what  he 
wants,  so  much  in  favor  of  the  higher  requirements. 

As  to  the  outlying  districts,  we  need  have  no  fear  as  long  as  the 
ratio  of  physicians  to  population  is  1  to  586^  and  the  use  of  the  auto- 
mobile is  increasing.  If  the  ratio  should  change  greatly,  which  does 
not  seem  likely,  for  only  two  states®  (North  and  South  Carolina)  have 
a  ratio  of  less  than  1  to  1,000,  the  matter  then  becomes  one  for  state 
regulation,  for,  as  the  report  of  the  Carnegie  Foundation  has  shown, 
we  have  enough  physicians,  but  the  difficulty  lies  in  the  tendency  of 
physicians  to  seek  the  larger  civic  centers. 

With  the  discussion  of  the  cultural  value  of  humanistic  as  compared 
with  scientific"  studies  we  are  not  concerned.  It  is  sufficient  that  in  a 
university  medical  school  a  man  can  not  properly  study  modern  medi- 
cine without  that  knowledge  which  comes  from  a  familiarity  with  labo- 
ratory work  in  physics,  chemistry  and  biology.  The  value  of  biological 
training  for  those  interested  in  practical  medicine  was  emphasized  by 
Huxley  many  years  ago,  and  that  in  physics  and  chemistry  has  recently 
been  emphasized  by  Friedrich  Miiller'^  in  describing,  for  the  benefit  of 
the  English  Commission,  the  training  of  the  German  medical  student. 

During  his  first  and  second  year,'  the  medical  student  attends  lectures  and 
does  laboratory  work  in  physics,  chemistry,  botany  and  zoology  in  the  philo- 
sophical faculty,  and  he  has  the  opportunity  of  widening  his  views  by  listening 
to  lectures  on  philosophical  or  historical  subjects.  His  teachers  and  laboratories 
are  the  same  as  for  the  students  of  the  natural  sciences,  and  this  is  right,  because 
there  is  no  such  thing  as  special  medical  physics  or  chemistry;  the  physician 
requires  a  broad  knowledge  of  the  general  sciences  of  physics  and  chemistry. 

It  is  most  important  to  have  this  statement  of  Miiller's  at  a  time 

Tlexner,  A.,  "Medical  Education  in  the  United  States  and  Canada,"  Bull. 
No.  4  of  the  Carnegie  Foundation  for  the  Advancement  of  Teaching,  1910. 

•  American  Medical  Association  Bulletin,  1910,  V.,  278. 

'  Miiller,  F.,  ' '  Memorandum  on  Medical  Education  Submitted  to  the  Royal 
Commission  on  University  Education  in  London." 

*  The  German  student  seldom  takes  his  state  examination  until  the  end  of 
five  and  a  half  years'  work  (Miiller), 


CHANCE    AND    THE    PEEP  ABED    MIND  129 

when  an  effort  is  being  made  to  place  physics,  chemistry  and  biology 
in  the  medical  curriculum.  With  or  without  a  fifth  year  it  is  a  danger- 
ous policy.  The  experience  of  one  school  in  this  regard  is  enlightening. 
During  the  period  of  change  from  a  high-school  to  a  two-year  college 
requirement,  conditioned  men  were  cared  for  by  allowing  time  in  the 
first  half  of  the  first  year  to  make  up  conditions.  The  procedure  took 
eighteen  hours  a  week  from  the  time  which  should  have  been  devoted 
to  purely  medical  studies.  In  such  an  emergency  as  that  of  a  change 
of  policy,  this  was  perhaps  justifiable,  but  what  university  school  with 
a  four-year  course  can  afford  this  arrangement  as  a  permanent  policy? 
And  if  we  are  to  have  a  fifth  year,  progress  demands  that  it  should  be 
a  clinical  or  hospital  year,  and  not  a  preliminary  year  for  work  which 
belongs  to  the  college.  The  modern  curriculum  of  a  first-grade  med- 
ical school  demands  a  student's  full  time  and  attention  and  no  amount 
of  general  culture  can  make  up  for  absence  of  prerequisites  in  physics, 
chemistry  and  biology.  The  school  which  allows  mixed  requirements, 
or  low  requirements  or  conditions,  does  so  at  the  expense  of  efficiency; 
the  good  men  suffer  on  account  of  the  slow  progress  of  the  poorly 
trained;  the  inefficiency  of  the  teaching  under  such  circumstances  be- 
comes noised  about,  and  it  comes  to  pass  that  the  best-trained  men  go 
to  schools  which  take  only  their  kind,  and  thus  eventually  low  standards 
react  on  the  school  allowing  them. 

But  this  is  not  all.  Another  factor,  the  state,  is  beginning  to  play 
an  important  part  in  determining  the  conditions  prerequisite  to  med- 
ical education.  Five^  states  have  passed  laws  demanding  that  for 
license  to  practise  medicine  an  applicant  must  have  had  two  years  of 
college  work  as  a  minimum  requirement,  and  four^*'  demand  one  year. 
This,  we  must  admit,  is  only  the  beginning.  As  state  after  state  adopts 
the  same  ruling,  schools  not  demanding  such  preparatory  study  must 
see  the  territory  open  to  their  graduates  (and  therefore  the  territory 
from  which  they  draw  students)  gradually  narrowed.  Certainly,  to- 
day, no  school,  and  certainly  no  university  school,  can  face  with  equa- 
nimity this  discrimination;  and  ''disappointed  indeed  will  be  that 
student  who,  after  having  spent  a  large  amount  of  time  and  money, 
finds  on  graduation  that  his  diploma  is  not  recognized  in  a  large  num- 
ber of  states."  ^^ 

*  Colorado,  Indiana,  Iowa,  Minnesota  and  North  Dakota. 

^''  Connecticut,  Kansas,  South  Dakota  and  Utah. 

11  Jour.  Am.  Med.  Assoc,  LVII.,  p.  1138,  1911;  LVIII.,  p.  487,  1912. 

10 


130  MEDICAL   BE  SEARCH   AND   EDUCATION 

Methods  of  Teaching. — Within  the  medical  school  itself  the  matter 
of  educational  policy  is  clear.  Here  there  can  be  only  one  procedure, 
the  constant  and  consistent  employment  of  the  "  do  it  yourself "  or 
"  learn  by  doing  "  method ;  the  student  must  be  taught  to  observe,  ex- 
periment, reason  and  act  for  himself.  This,  I  know,  is  trite,  but  the 
conditions  out  of  which  our  present  methods  of  medical  education  have 
emerged  demand  that  this  point  of  view  be  continually  emphasized.  It 
is  not  long  since  the  day  of  the  two  and  three  year  course  and  the  im- 
parting to  undergraduates  of  all  medical  instruction,  outside  of  anat- 
omy and  inorganic  chemistry,  by  lecture.  The  development  of  the 
laboratory  branches — histology,  pathology,  bacteriology,  physiological 
chemistry  and  pharmacology — and  the  cheapening  of  physiological 
apparatus,  have  given  a  new  turn  to  medical  teaching,  that  of  active 
participation  by  the  student.  But  still  even  in  these  branches  the  lec- 
ture still  persists  in  most  schools  and  frequently  is  so  magnified  in  con- 
nection with  the  laboratory  instruction  as  to  make  it  appear  in  the  eyes 
of  the  student  as  the  most  essential  part  of  the  course.  The  advance 
in  methods  and  means  of  practical  laboratory  instruction — that  is,  the 
visible  machinery  for  developing  the  principle  of  teaching  by  actual 
observation  and  experiment — would  seem  in  some  schools  to  be  an 
equipment  for  advertising  purposes  only.  One  does  not  have  to  go  out- 
side the  group  of  our  so-called  "  big  "  schools  to  find  a  department  of 
pathology,  abundantly  equipped  with  apparatus  and  a  wealth  of  patho- 
logic material,  offering  five  lectures  a  week;  and  one  may  find  an  elab- 
orately equipped  student's  laboratory  of  physiology  manned  by  assist- 
ants while  the  head  of  the  department  fulfills  his  duty  to  his  class  with 
three  or  four  lectures  a  week;  and  likewise,  in  the  clinical  branches, 
few  men  have  had  the  courage  to  do  away  with  frequent  and  voluminous 
lectures.  Even  schools  controlling  a  large  hospital,  and  sometimes 
several,  and  thus  having  an  abundance  of  clinical  material,  do  the 
bulk  of  their  teaching  by  the  formal  lecture  and  the  amphitheater 
clinic.  The  ward  class  and  the  clinical-clerk  system  gain  ground  but 
slowly.  The  reason  for  this  attitude  is  easily  found.  The  lecture  is  the 
easiest  form  of  teaching,  and  the  average  teacher,  whether  he  be  the 
laboratory  man  overburdened  by  executive  detail  and  handicapped  by 
lack  of  assistants,  or  the  clinical  teacher  limited  in  time  by  a  busy  prac- 
tise, follows  the  lines  of  least  resistance,  forgetful,  though  sometimes 
resentfully  so,  of  the  best  needs  of  his  class.    Usually  coexistent  with  a 


CHANCE    AND    THE   PSEPAEED   MIND  131 

pernicious  lecture  system  is  the  habit  of  leaving  those  most  favorable 
fields  for  proper  education — the  laboratory  exercise  and  the  ward  or 
dispensary  class — to  assistants.  No  one  has  less  desire  to  belittle  the 
work  of  assistants  or  to  lessen  their  independence  than  have  I,  but  in 
the  department  in  which  the  head  lectures  only  the  student  naturally 
assumes  that  the  work  of  subordinates — in  laboratory  or  clinic — must 
be  work  of  subordinate  importance,  and  thereby  he  comes  to  have  a 
wrong  estimate  of  the  live  part  of  his  education.  The  most  ardent  sup- 
porter of  the  lecture  system  can  not  say  that  he  always  holds  the  in- 
terest of  his  class.  He  may  hold  their  attention  and  be  flattered  by 
copious  note-taking,  but  this  has  for  its  object  only  one  purpose — the 
final  examination.  The  real  education — the  training  which  means 
power  and  which  characterizes  "  the  mind  which  is  prepared  " — can 
come  only  through  independent  but  wisely  directed  observation,  ex- 
periment and  reasoning  on  the  part  of  the  student. 

I  have  discussed  elsewhere^-  how  the  latter  system  may  be  fostered, 
and  am  now  glad  to  be  able  to  reinforce  my  position  by  quoting  from 
the  recent  very  excellent  address  on  this  subject  by  Professor  G.  M. 
Jackson.^^    As  to  the  share  of  the  teacher  Professor  Jackson  says : 

It  is  evident  that  each  teacher  must  understand  the  curriculum  as  a  whole. 
The  laboratory  man  must  be  familiar  with  the  clinical  work.  But  this  is  not  all. 
Since  good  teaching  must  take  into  account  that  which  has  gone  before  as  well 
as  that  which  is  to  follow,  it  is  equally  evident  that  the  clinical  man  must  be 
familiar  with  laboratory  subjects  and  methods.  We  can  not  expect  the  best 
results  in  medical  education  until  there  is  a  better  understanding  and  more 
cooperation  between  teachers  of  the  various  subjects  all  along  the  line.  As 
medicine  progresses,  all  phases  appear  more  clearly  as  varied  manifestations  of 
the  same  underlying  biological  science,  and  only  when  this  is  realized  will  the 
clinical  and  laboratory  work  be  more  closely  knitted  together. 

As  for  the  student,  it  is  suggested  that  he 

work  out  everything  for  himself  by  the  method  of  discovery.  This  applies  not 
only  to  the  original  observations,  but  also  to  the  latter  process  of  reasoning, 
whereby  we  proceed  from  particular  data  to  general  conclusions,  and  thence  to 
rational  action.  The  method  of  self-activity  may  therefore  be  expressed  in  a 
negative  way  by  the  following  practical  rules:  Never  tell  a  student  anything  he 
can  observe  for  himself;  never  draw  a  conclusion  or  solve  a  problem  which  he 
can  be  led  to  reason  out  for  himself;  and  never  do  anything  for  him  that  he 
can  do  for  himself. 

"  '  *  The  Experimental  Method :  Its  Influence  on  the  Teaching  of  Medicine. ' ' 
Printed  in  this  volume. 

"Jackson,  G.  M.,  "On  the  Improvement  of  Medical  Teaching,"  Science, 
XXXV.,  p.  56&,  1912. 


132  MEDICAL    BESEABCH    AND    EDUCATION 

There  are,  of  course,  limitations  to  the  application  of  this  method, 
as  lack  of  time,  an  overcrowded  curriculum,  inability  on  the  part  of  the 
teacher  to  fully  grasj)  the  situation,  and  failure  to  always  maintain 
sustained  effort  on  the  part  of  the  student,  but  its  value  over  the  lec- 
ture system  is  so  great  that  it  should  be  followed  in  "  so  far  as  prac- 
ticable "  (Jackson)  and  should  be  supplemented  by  demonstrations 
and  conferences  or  recitations  rather  than  by  lectures,  if  one  truly 
seeks  to  prepare  properly  for  the  practise  of  medicine. 

Influence  of  the  Spirit  of  Investigation. — But  aside  from  this  train- 
ing the  university  has  another  duty  to  the  prospective  practitioner  of 
medicine.  This  is  its  duty  in  the  encouragement  of  investigation,  which 
is  indeed  a  double  duty,  a  duty  to  its  students  and  a  duty  to  the  com- 
munity it  serves. 

The  question  of  allowing  undergraduates  to  undertake  independent 
original  investigation  is,  I  know,  a  debatable  one.  Certainly  in 
most  schools  our  overcrowded  curriculum  renders  such  work  impos- 
sible unless  a  wise  arrangement  allows  elective  studies,  as  at  Harvard 
in  the  fourth  year,  or  as  at  Johns  Hopkins  in  each  year.  My  remarks 
on  this  subject-^are  therefore  based  on  the  assumption  that  an  elective 
system  is  possible  in  every  school. 

As  every  teacher  knows,  each  class  contains  a  considerable  number 
of  men  who  desire  to  pursue  work,  to  a  greater  extent  than  the  conven- 
tional course  allows,  on  certain  subjects  or  by  special  methods,  or  less 
frequently,  perhaps,  they  desire,  and  are  usually  well  qualified  to  under- 
take, minor  investigative  work.  To  the  former,  as  well  as  to  the  latter, 
any  effort  spent  in  work  beyond  that  given  the  entire  class  becomes, 
necessarily,  for  them,  the  acquirement  of  the  methods  of  research  and 
as  this  means  a  knowledge  of  the  exact,  painstaking  methods  by  which 
the  realms  of  the  unknown  are  explored,  it  is  an  exercise  wliich  pre- 
pares the  student  for  the  daily  routine  research  work  of  the  physician 
who  truly  practises  his  profession.  As  a  training  for  future  work  its 
value  is  definitely  known,  and  the  increased  zest  and  enthusiasm  ex- 
hibited toward  their  medical  work  by  men  who  have  had  this  oppor- 
tunity are  always  evident.  Pedagogically,  therefore,  it  would  seem  ad- 
visable that  every  student  should  have  the  opportunity  for  minor  in- 
vestigative effort,  in  order  that  he  may  become  acquainted  at  first  hand 
with  the  careful  methods  of  experimental  medicine.  The  bearing  of 
the  tangible  results  of  his  work  on  the  subject  investigated  is  a  matter 


CHANCE   AND    THE    PEEPAEED   MIND  133 

of  little  or  no  importance ;  the  vital  thing  is  the  increased  power  which 
he  himself  acquires. 

There  is  another  way  in  which  the  encouragement  of  research  aids 
the  student,  but  which  is  possible  only  to  those  schools  following  the 
wise  policy  of  appointing  to  professorial  chairs  teachers  who  are  like- 
wise investigators.  The  influence  of  such  teachers  in  the  development 
of  independent  and  resourceful  practitioners  is  the  secret  of  the  great 
success  of  our  better  schools.  The  correctness  of  this  statement  may  be 
easily  demonstrated. 

If  one  examines  courses  in  the  same  subject  in  a  number  of  schools 
it  is  found  that  those  which  are  best  presented  are  under  the  control  of 
men  actively  engaged  in  research  work.  Such  men  are  alive  to  the  ad- 
vantages of  new  methods  in  their  own  subject  and  of  new  ways  of  ap- 
plying old  methods.  Ever  tliinking  and  pondering  about  new  methods 
of  acquiring  knowledge  for  themselves  and  their  science,  they  appreci- 
ate better  than  does  the  non-investigator  that  which  will  aid  the  stu- 
dent to  acquire  knowledge,  and  in  their  teaching  they  bring  to  bear  on 
the  problems  which  the  student  has  to  face  the  same  methods  of  attack 
which  they  use  in  their  own  researches.  On  the  other  hand,  one  finds 
the  men  who  never  or  only  occasionally  contribute  to  the  literature  of 
their  science  are  the  men  who  confine  their  teaching  to  perfunctory 
routine  courses,  with  a  profusion  of  lectures,  and  w^ho  never  bring  the 
spirit  or  methods  of  the  investigator  into  their  teaching.  So,  likewise, 
it  is  with  the  student  taught  under  these  two  conditions.  The  student 
who  knows  that  he  is  working  in  a  department  actively  emphasizing 
new  methods  and  striving  to  develop  new  truths,  knows  that  his  in- 
struction is  presented  in  the  spirit  of  the  department,  and  thus  re- 
ceives that  stimulus  and  inspiration  which  insures  his  approaching  clin- 
ical medicine  with  a  proper  appreciation  of  the  scientific  method.  The 
student  under  the  method  of  the  non-investigator,  on  the  contrary,  has 
no  incentive  other  than  that  of  acquiring  a  knowledge  suSicient  to  allow 
him  to  pass  an  examination. 

An  allied  argument  lies  in  the  fact  that  the  medical  school  that 
fosters  research  attracts  the  best-trained  men  as  students.  We  have, 
as  is  well  known  to  many  of  you,  a  medical  school  in  this  country  which 
has,  for  several  years,  arbitrarily  selected  from  a  larger  number  of  pros- 
pective matriculants  the  certain  definite  number  which  it  desires;  the 
rest,  sometimes  nearly  fifty  per  gent,  of  those  accepted,  go  elsewhere. 


134  MEDICAL   BESEABCH   AND    EDUCATION 

Now  this  school  has  the  highest  requirements  and  perhaps  the  smallest 
alumni  body  of  any  prominent  school  in  the  country.  It  is  not,  there- 
fore, a  question  of  easy  entrance  or  of  the  loyal  influence  of  alumni, 
nor  is  it  a  question  of  better  laboratory  and  hospital  facilities,  for  other 
schools  have  equally  good  equipment  in  both  respects.  Likewise  it  is 
not  a  question  of  geographic  location  or  center  of  population.  The 
enviable  position  of  this  school  is  due  solely  to  the  policy  of  combining 
research  with  teaching  and  of  appointing  to  its  staff  teachers  who,  with 
few  exceptions,  are  also  investigators. 

As  to  the  duty  of  the  university  to  the  community  in  the  matter  of 
research,  there  can  be  only  one  opinion.  If  the  purpose  of  the  ma- 
chinery of  medical  education  is  to  "  bring  healing  to  the  nations,"  if 
the  business  of  medicine  is  to  "  get  people  out  of  difiiculties  through 
the  application  of  science  and  dexterity,  manual  and  physical "  (Cabot), 
then  it  is  the  duty  of  the  university  not  only  to  teach  known  principles 
and  methods,  but  to  advance  knowledge  and  methods  by  research. 

It  is  futile  to  say  that  it  is  sufficient  to  teach  and  to  utilize  known 
methods  of  freeing  people  from  difficulties,  for  the  mere  statement  of 
such  an  attitude  implies  that  an  obligation  exists  to  extend  known 
methods,  or  to  invent  new  ones,  in  the  hope  of  overcoming  difficulties 
acknowledged  to  be  at  present  without  remedy.  The  ethical  force  of 
this  statement  can  not  be  denied.  To  teach  a  subject  implies  the  at- 
tempt to  diffuse  the  available  knowledge  of  that  particular  subject-mat- 
ter among  a  number  of  people  for  their  good,  as  well  as  for  the  good 
of  the  community  in  which  they  live  and  work;  equally  true  is  it  that 
such  an  attempt  to  teach  available  knowledge  imposes  upon  the  teacher 
the  obligation  to  leave  untried  no  means  by  which  the  knowledge  of  his 
subject  may  be  increased.  It  is  not  the  privilege  of  the  teacher  to  leave 
this  extension  of  knowledge  to  others.  His  profession  of  ability  to  teach 
a  particular  subject  carries  with  it  his  obligation  to  the  group  or  com- 
munity he  serves,  of  adding  to  his  subject  knowledge  of  which  they  may 
avail  themselves.  If  this  applies  to  the  individual  teacher,  how  much 
more  forcibly  does  it  apply  to  the  university  with  its  ever-widening  com- 
munity and  ever-increasing  interests? 

On  the  other  side  of  the  question,  the  university  should  not  forget 
that  medical  research  tends  to  ameliorate  social  conditions  by  dimin- 
ishing the  causes  of  physical  and  mental  ills.  This  ideal  of  medicine 
the  university  and  its  community  should  foster  and  develop,  for  it  is 


CHANCE   AND    THE    PEEP  ABED   MIND  136 

one  of  the  greatest  influences  in  our  modern  conception  of  social  serv- 
ice; an  influence,  indeed,  which  was  back  of  all  Pasteur's  work,  and 
which  he  expressed  in  the  statement  of  his  desire  to  contribute  "  in  some 
manner  to  the  progress  and  welfare  of  humanity." 

But  aside  from  this  altruistic  ideal,  I  hold  that  research  in  the  med- 
ical school  offers  important  practical  advantages  to  the  university  and 
that  these  advantages  should  not  be  forgotten  by  university  authorities 
who  pride  themselves  on  applying  business-like  methods  to  the  prob- 
lems of  education.  A  policy  which  attracts  a  better-trained  class  of 
students,  which  improves  the  character  of  the  instruction,  which  stim- 
ulates the  student  to  a  better  type  of  individual  effort  and  which  en- 
hances the  standing  of  the  university  in  the  community  and  the  nation, 
is  a  policy  which  can  not  be  ignored  by  university  president,  trustees  or 
faculty. 

The  Relation  of  the  Hospital  to  Medical  Teaching  and  Research. — 
That  the  laboratories  of  our  better  medical  schools  are  fully  equipped 
for  the  kind  of  instruction  which  I  have  outlined,  and  that  many  are 
already  fostering  the  "do  it  yourself"  principle  and  the  spirit  of  in- 
vestigation, is  well  known.  In  the  clinical  years,  on  the  other  hand,  the 
situation  is  not  so  satisfactory.  Many  a  medical  school  while  building 
and  equipping  modern  laboratories  has  failed  to  care  properly  for  its 
clinical  teaching,  and  has  continued  to  foster  the  amphitheater  lecture. 
If  the  method  of  first-hand  instruction,  which  I  have  outlined,  is  to  be 
followed,  then  the  hospital  must  become  the  laboratory  of  the  clinical 
years  and  a  school  must  own.  or  absolutely  control  its  hospital.  This  is 
necessary  in  order  (1)  that  the  heads  of  the  clinical  departments  may 
have  a  continuous  service  under  their  immediate  charge  and  to  the 
conduct  of  which  they  may  bring  their  own  assistants ;  ( 8 )  that  in  con- 
nection with  such  service  they  may  develop  laboratories  for  teaching 
and  research  in  addition  to  the  usual  clinical  laboratory  now  used  only 
for  purposes  of  diagnosis;  and  (3)  that  resident  physicians  may  be 
appointed  for  indefinite  service  in  order  that  trained  teachers  and  in- 
vestigators in  clinical  medicine  may  be  produced  in  the  same  way  as 
trained  teachers  and  investigators  in  the  laboratory  branches  are  now 
produced,  and  (4)  that  the  head  of  the  department  may  provide  ade- 
quately for  that  intimate  first-hand  clinical  instruction  which  can  be 
secured  only  by  placing  the  student  in  actual  contact  with  the  patient. 

Some  schools,  as  Michigan,  Pennsylvania,  Hopkins  and  Jefferson, 


136  MEDICAL   BESEABCH   AND    EDUCATION 

have  already  solved  the  problem  by  the  establishment  of  their  own  hos- 
pitals. This  is  naturally  the  ideal  course  for  all  university  schools  and  a 
future  for  which  every  school  should  plan.  But  in  the  absence  of  the 
possibility  of  immediate  consummation  of  such  an  ideal,  results  almost  as 
satisfactory  may  be  obtained  by  the  actual  affiliation  of  municipal  or 
independent  hospitals  with  the  stronger  medical  schools.  A  hospital  has 
as  much  to  gain  by  this  arrangement  as  has  the  medical  school,  for 
while  the  chief  duty  of  the  hospital  must  always  be  the  care  of  the  sick 
and  injured,  this  duty,  as  well  as  its  other  functions — the  instruction 
of  men  who  are  to  practise  medicine  and  the  advancement  of  medical 
knowledge  by  research — is  best  served  by  placing  the  conduct  of  the 
hospital  in  the  hands  of  men  highly  trained  in  the  methods  of  scien- 
tific medicine.^*    This  would  not  only  enable  the  hospitals 

to  fulfill  a  greater  function  in  the  development  of  thoroughly  qualified  physicians, 
but  it  would  also  be  best  for  the  patients,  since  they  would  have  the  benefit  of 
the  best  methods  of  treatment  under  recognized  experts.  A  campaign  of  educa- 
tion should  be  carried  on  to  show  our  municipal  authorities  that  the  hospital  will 
be  the  best  conducted  in  the  interests  of  its  patients,  and  the  community  at  large, 
if  at  the  same  time  it  is  fulfilling  its  function  as  a  great  center  of  clinical 
teaching  and  resear,ch." 

Many  examples  may  be  presented  of  the  ideal  association  of  charity, 
teaching  and  research  as  the  results  of  such  affiliation;  the  most  stri- 
king perhaps  being  the  magnificent  clinic  of  Miiller  in  Munich  and  the 
clinics  of  the  University  of  Leipzig.  Here,  as  in  many  other  conti- 
nental cities  and  in  England,  the  university  authorities  by  agreement 
with  the  municipal  authorities  appoint  the  heads  of  the  hospital  clin- 
ics. The  long  continuance  of  this  arrangement  and  the  great  fame  of 
most  of  these  clinics  are  sufficient  proof  that  both  municipal  authorities 
and  university  authorities  find  it  mutually  advantageous. 

We  should  bring  about  the  same  state  of  affairs  in  this  country,  and,  in  fact, 
a  start  has  already  been  made.  At  Cincinnati  the  large  municipal  hospital  has 
been  placed  in  charge  of  the  clinical  teachers  of  the  University  of  Cincinnati; 
in  St.  Louis,  the  Washington  University  has  made  a  close  affiliation  with  the 
new  Barnes  Hospital;  in  Boston,  Harvard  has  made  an  affiliation  with  the  Peter 
Brigham  and  several  other  special  hospitals;  in  New  York,  Columbia  University 
and  the  Presbyterian  Hospital  have  established  similar  relations;  in  Cleveland, 

"  For  a  discussion  of  the  advantages  to  be  gained  by  the  hospital,  see 
Welch,  W.  H.,  "Advantages  to  a  Charitable  Hospital  of  Affiliation  with  a 
University  Medical  School,"  The  Survey,  XXVII.,  p.  1766,  1912. 

15  Bevan,  A.  D.,  "  The  Modern  Medical  School,"  Jour.  Am.  Med.  Assoc, 
LVIII.,  p.  652,  1912. 


CHANCE    AND    THE    PEEP  AS  ED   MIND  137 

Western  Eeserve  University  has  formed  a  combination  with  the  Lakeside  Hos- 
pital; in  Chicago,  Eush  Medical  College  has  had  for  a  number  of  years  the 
medical  control  of  the  Presbyterian  Hospital,  and  recently  has  made  similar 
contracts  and  arrangements  with  the  Children 's  Memorial  Hospital,  the  Home  for 
Destitute  Crippled  Children  and  the  Hospital  for  Infectious  Diseases.'* 

How  much  better  such  an  arrangement  would  be  than  that  which 
now  exists.  At  present  in  most  schools  the  clinical  teacher  is  a  teacher 
mainly  because  he  is  fortunate  enough  to  control  a  hospital  service,  and 
for  this  reason  has  been  appointed  on  the  university  staff.  In  his  ap- 
pointment the  school  has  no  choice,  for  it  must  have  for  its  students 
the  advantages  of  the  clinical  material  which  he  controls.  Whether  he 
be  good,  bad  or  indifferent,  as  physician,  teacher  or  investigator,  he 
must  be  retained  as  long  as  he  holds  his  hospital  position.  He,  on  the 
other  hand,  is  handicapped  by  the  regulations  and  restrictions  of  a  not 
always  sympathetic  lay  board  of  hospital  management  and,  more  im- 
portant still,  by  the  absence  of  proper  laboratory  facilities  and  the  aid 
of  his  own  colleagues  in  the  departments  of  bacteriology,  immunology, 
pathology  and  pathological  chemistry.  These  departments  are  com- 
ing more  and  more  into  active  participation  in  hospital  work,  in  diag- 
nosis, prognosis  and  treatment,  and  should  be  as  closely  affiliated  with 
the  hospital  as  are  the  clinical  chairs.  Those  of  you  who  have  read 
"  The  Corner  of  Harley  Street,"  ^'^  a  most  delightful  series  of  letters 
by  an  English  consultant,  may  remember  the  words  quoted  by  the  au- 
thor from  a  lecture  of  a  brother  physician  to  postgraduates.  Said  the 
lecturer : 

Gentlemen,  I  should  like  the  day  to  dawn  when  I  could  be  met  at  the  door 
of  my  hospital  by  a  trained  chemist,  a  trained  bacteriologist,  a  trained  pathol- 
ogist, so  that  when  I  come  to  some  complicated  case  I  could  say,  "Chemist,  a 
part  of  this  problem  is  yours,  take  it  and  work  it  out.  Bacteriologist,  perform 
your  share  in  elucidating  this  difficulty.    Pathologist,  advance,  and  do  likewise. ' ' 

These  are  not  idle  words.      Since  Ziemssen  in  the  middle  eighties 

established  in  Munich  the  principle  of  a  clinical  laboratory  in  the 

hospital,  the  idea  has  spread  rapidly,  until  now  every  hospital  worthy 

of  the  name  has  its  clinical  laboratory  for  the  routine  procedures  of 

diagnosis.      But  this  is  not  sufficient.      The  clinical  chief  must  have 

the  close  cooperation  of  his  colleagues  in  the  departments  of  pathology, 

bacteriology,  physiology  and  chemistry,  and  the  student  likewise  must 

'°  Bevan,  loc.  cit. 

" ' '  The  Corner  of  Harley  Street,  being  some  Familiar  Correspondence  of 
Peter  Harding,  M.D.,"  Houghton  Mifflin  Co.,  1911. 


138  MEDICAL   BESEAECH   AND    EDUCATION 

have  the  outfits  of  these  departments  at  hand  to  aid  him  in  his  clinical 
studies.  It  is  no  longer  enough  to  depend  on  the  simpler  procedures 
for  the  examination  of  urine,  sputum,  blood  and  other  body  secretions 
and  fluids.  The  transportation  across  the  city  of  tissues  or  fluids  for 
examination  in  the  laboratories  of  the  school  can  no  longer  be  counte- 
nanced. The  progress  of  modern  medicine,  especially  in  pathological 
chemistry  and  immunology,  demands  for  the  benefit  of  the  patient,  as 
well  as  for  the  proper  instruction  of  the  student,  detailed  and  often- 
times prolonged  examinations  under  the  hospital  roof  or  at  least 
within  the  boundaries  of  the  hospital  yard,  and  under  the  control  not 
of  assistants  or  internes,  or  dependent  on  occasional  visits  of  a  professor 
of  pathology,  bacteriology  or  chemistry,  but  vinder  the  constant  super- 
vision of  such  experts  who  do  their  teaching  and  research  in  the 
hospital  and  contribute  their  share  to  the  diagnosis,  care  and  treatment 
of  the  ills  of  the  patients.  This  is  the  ideal  of  social  service  in  medi- 
cine, the  goal  of  all  effort  in  medical  education  and  research ;  and  it  is 
not  Utopian.  Already  the  University  of  Toronto  has  transferred  its 
departments  of  pathology,  bacteriology  and  pathological  chemistry  to 
the  grounds  of  the  hospital  which  furnishes  its  clinical  instruction. 
Here  not  only  the  elementary  instruction  is  given,  largely  aided  by  an 
abundance  of  fresh  material  from  the  hospital,  but  each  advanced 
student  serving  as  clinical  clerk  in  the  wards  has  always  his  desk,  well- 
equipped  locker  and  special  outfit  for  the  detailed  investigation  of  his 
clinical  material  by  laboratory  methods,  and,  moreover,  has  always  at 
hand  his  teachers  in  the  laboratory  branches  to  aid  him  in  his  clinical 
investigations.  It  was  my  good  fortune  recently  to  go  over  these 
departments  with  Professors  Leathes  and  MacKenzie,  who  explained 
their  workings  to  me.  When  I  expressed  my  satisfaction  at  the  ideal 
union  of  clinical  and  laboratory  methods  Professor  Leathes  said  quietly, 
and  as  if  there  could  be  no  other  point  of  view,  "Yes,  we  expect  a 
student  working  in  the  wards  to  use  in  diagnosis  the  methods  of  patho- 
logical chemistry  as  he  does  his  stethoscope."  Do  you  know  what  this 
means  ?  It  means  that  the  amphitheater  clinic  and  the  didactic  lecture 
are  to  follow  the  two-year  and  three-year  course  and  that  the  methods 
and  instruction  of  the  laboratory  years  are  no  longer  to  be  divorced 
from  the  clinical  teaching  of  the  later  years  of  the  curriculum.  It 
means  that*  men  are  to  be  trained  by  the  "  do  it  yourself  "  method  to 
become  practitioners  with  power  of  accurate  diagnosis  and  the  "  mind 


CHANCE    AND    THE    PEEPABED    MIND  139 

which  is  prepared  "  to  take  advantage  of  every  "  chance  "  observation 
and  opportunity.  It  means  that  the  newer  methods  of  biological, 
physical  and  chemical  diagnosis,  evolved  through  laboratory  effort,  are 
to  work  a  transformation  in  medical  teaching  and  medical  practise 
analogous  to  that  which  came  in  the  middle  of  the  past  century  through 
the  introduction  of  exact  methods  of  physical  examination.  As  phys- 
ical diagnosis  raised  medicine  above  the  plane  of  objective  diagnosis 
and  revealed  the  morphological  changes  in  diseased  organs  of  the 
interior  of  the  body,  so  now  the  methods  of  physiological  chemistry 
and  immunology  are  destined  to  reveal  the  changes  in  the  cells  and 
fluids  of  the  body  which  are  dependent  on  intoxication,  infection  and 
altered  metabolism  and  thus  bring  about  an  advance  in  methods  of 
diagnosis,  the  fruits  of  which  are  almost  beyond  our  powers  of 
imagination. 

Herein  lies  the  most  potent  argument  for  close  affiliation  of  school 
and  hospital.  The  task,  both  from  the  teaching  side  and  from  the 
research  side,  demands  united  effort,  common  use  of  material  and 
common  financial  responsibility.  While  any  contract  between  univer- 
sity and  hospital  must  leave  the  general  support  of  the  hospital  in  the 
hands  of  the  hospital  management,  the  school  must  be  prepared  to  pay 
the  salaries  of  attending  staff,  the  cost  of  equipment  and  the  expenses 
necessary  for  teaching  and  research  and  to  assume  the  responsibility 
for  the  medical  and  surgical  care  of  the  patients  and  the  general  con- 
duct of  the  scientific  work.  On  the  other  hand,  the  hospital  should 
leave  the  matter  of  appointments,  subject  to  its  nominal  approval, 
entirely  in  the  hands  of  the  school,  with  the  understanding  that  with- 
drawal or  resignation  from  the  school  automatically  would  sever  con- 
nection with  the  hospital,  and  vice  versa.  Such  an  arrangement  settles 
most  of  the  problems  of  medical  education. 

The  Hospital  Year. — So  much  for  the  preparation  which  the  train- 
ing, facilities  and  opportunities  of  the  modern  medical  school  should 
offer  as  leading  to  the  degree  of  doctor  of  medicine.  Should  the  state 
and  the  public  demand  more?  Yes,  the  state,  through  its  machinery 
for  the  protection  of  the  individual,  should  demand  a  fifth  year  of 
hospital  work,  and  this  the  public  would  force  the  state  to  demand  if 
the  easy-going  public  was  thoroughly  familiar  with  the  insufficient 
requirements  of  many  of  our  state  licensing  boards.  Indeed,  some 
states  are  already  drafting  laws  to  protect  their  citizens  from  the 
products  of  the  poor  medical  schools  of  a  neighboring  state — 


140  MEDICAL   RESEABCH   AND    EDUCATION 

For  example,  the  state  of  Minnesota  has  enacted  a  law  enforcing  an  educa- 
tional qualification  as  to  the  training  of  physicians  who  are  allowed  to  practise 
in  that  state.  The  law  was  adopted  in  order  to  protect  citizens  of  Minnesota 
against  the  graduate  of  commercial  medical  schools  in  neighboring  states,  and 
particularly  of  Chicago.  In  the  present  state  of  medical  education  such  a 
measure  is  entirely  justifiable.^* 

Sucli  a  law  not  only  protects  the  community  against  the  improperly 
prepared  graduates  of  the  poor  school,  but  it  encourages  the  good 
medical  school  to  increased  efforts. 

The  hospital  year  as  a  prerequisite  to  licensure  is  to-day  a  live  topic 
of  discussion ;  to-morrow  it  may  be  in  this  and  in  other  states  a  require- 
ment legally  stated.^^  Indeed  it  is  difficult  to  see  how  the  progressive 
state  of  New  York,  the  educational  system  of  which  is  so  wisely  con- 
trolled by  a  special  board  of  regents,  can  much  longer  delay  in  estab- 
lishing such  a  requirement.  But  why  wait  for  the  regents  to  force 
this  upon  the  schools?  Already  80  to  90  per  cent,  of  the  men  in  the 
better  schools  secure  hospital  appointments.  Why  should  not  the 
schools  compel  the  small  minority  of  those  who  do  not  secure  a  hospital 
to  take  a  fifth  year  in  clinical  instruction  in  the  hospital  which  it  con- 
trols and  thus  be^prepared  for  the  requirement  which  must  inevitably 
come  in  this  and  other  states.  I  realize  fully  that  the  deans  of  our 
various  schools  are  divided  on  this  question.  Some  take  the  position 
that  although  the  hospital  year  is  an  excellent  requirement,  the  burden 
of  finding  the  hospital  instruction  for  all  its  graduates  should  not  be 
placed  on  the  school ;  that  the  duty  of  the  university  is  ended  when  it 
has  given  four  years  of  instruction  and  that  the  fulfillment  of  the  added 
requirement  is  an  affair  of  the  individual.  What  does  this  mean  in 
the  last  analysis?  Simply  this,  that  a  school  holding  this  point  of 
view  is  either  lax  in  its  entrance  requirements  or  at  fault  in  its  methods 
of  instruction;  otherwise  it  would  not  fear  the  failure  of  its  graduates 
to  secure  interneships.  If  this  is  true  it  has  under  the  circumstances 
but  one  duty:  as  an  educational  institution,  it  must  itself  provide  the 

^*  Pritchett,  H.  S.,  ' '  Education  and  the  Nation, ' '  The  Atlantic  Monthly, 
April,  1912. 

"  There  is  only  one  school  at  present  which  requires  the  fifth  hospital  year, 
and  that  is  the  University  of  Minnesota.  No  state  boards  at  present  require  the 
hospital  interne  year.  Those  which  to  a  certain  extent  have  initiated  practical 
tests  at  their  examinations  are  Massachusetts,  Minnesota,  Ohio  and  North 
Dakota,  and  to  a  lesser  extent  practical  tests  are  being  used  in  Colorado  and 
Michigan.  (Personal  communication  from  N.  P.  Colwell,  secretary,  Council  on 
Medical  Education  of  the  American  Medical  Association.) 


CHANCE   AND    TEE    PEEPAEED    MIND  141 

fifth  year  of  hospital  work  for  its  lame  students.  This  is  the  point  of 
view  which  is  gradually  forcing  itself  upon  the  school  of  the  better 
grade,  which,  now  that  the  pioneer  stage  of  medical  education  is  past, 
desires  to  itself  complete  the  student's  preparation,  instead  of  turning 
him  "  over  to  others  during  this  most  valuable  and  important  part  of 
his  preparatory  work."  ^°  The  proposition  of  Professor  Peterson,  of 
Michigan,  that  the  council  on  medical  education  of  the  American 
Medical  Association  should  conduct  an  inspection  and  classification  of 
hospitals  on  the  same  basis  as  the  inspection  of  medical  schools  is  most 
timely.  The  data  thus  obtained  would  do  much  to  clarify  the  situa- 
tion, and,  doubtless,  mutual  agreements  between  certain  schools  and 
certain  hospitals  of  the  same  class  could  be  reached  as  to  the  distribu- 
tion of  graduates  for  interne  service.  Such  a  systematization  would 
allow  school  and  hospital  alike  to  see  their  defects  and  so  rearrange 
their  work  as  properly  to  care  for  the  greatest  number  of  properly  pre- 
pared men.  Only  through  the  hospital  year  can  we  give  the  best  type 
of  practitioners  to  a  most  deserving  but  too  confiding  public;  but  to 
bring  about  the  consummation  of  this  ideal  every  university  school  and 
every  community  possessing  a  modern  hospital  must  do  its  share. 

These  general  remarks  cover,  in  my  opinion,  the  cardinal  principles 
which  should  guide  the  modern  medical  school.  They  can  not,  per- 
haps, in  every  community,  be  enforced  at  once  in  their  entirety,  and 
doubtless  now  and  then  their  adoption  may  be  followed  by  backsliding, 
but  no  one  who  has  given  the  subject  serious  thought  can  doubt  that 
the  future  of  medical  education  in  this  country  depends  on  (1)  the 
university  school  with  a  high  entrance  requirement,  (2)  instruction,  in 
both  laboratory  and  clinical  branches,  based  on  the  method  of  observa- 
tion and  experiment,  (3)  clinical  instruction  in  a  hospital  which  the 
university  owns  or  controls,  (4)  the  principle  of  a  fifth  year  of  hos- 
pital instruction  and  (5)  the  fostering  of  the  spirit  of  research. 

And  now  finally  let  me  congratulate  Syracuse  University  on  the 
high  ideals  it  has  set  itself  in  the  conduct  of  its  medical  school.  Your 
course  has  been  watched  by  all  who  are  interested  in  medical  educa- 
tion. Your  responsibility  is  greater  than  perhaps  you  realize ;  there  are 
those  praying  for  you  to  continue  your  present  progressive  system, 
others  hoping  you  may  fail.    Each  group  desires  to  point  to  you  as  an 

'"  See  Peterson,  E.,  ' '  The  Relation  of  the  Medical  School  to  the  Interne  or 
Hospital  Year/'  Jour.  Am.  Med.  Assoc,  LVIII.,  p.  723,  1912. 


142  MEDICAL   BESEABCH   AND   EDUCATION 

object-lesson.  I  have  full  confidence,  however,  that  the  wise  trustees  of 
your  university,  supported  and  encouraged  by  your  alumni  and  the 
physicians  of  Syracuse  and  its  surrounding  territory,  will  not  only 
maintain  the  present  high  standards,  but  will  inaugurate  still  greater 
advances  and  thus  ensure  for  the  practitioner  of  medicine  in  this  com- 
munity the  "prepared  mind"  of  Pasteur's  adage. 


4 


THE  INTEEDEPENDENCE  OF  MEDICINE  AND  OTHEE 
SCIENCES  OF  NATUEE^ 

By  William  H.  Welch,  M.D.,  LL.D., 

Professor  of  Pathology,  The  Johns  Hopkins  University 

Sixty  years  ago,  when  the  American  Association  for  the  Advance- 
ment of  Science  was  founded,  all  of  the  main  divisions  of  the  sciences 
of  nature  existed  as  they  do  to-day,  but  no  greater  change  has  come  over 
the  face  of  science  during  these  years  than  the  many  subdivisions  which 
have  arisen.  Then  the  naturalist  or  the  natural  philosopher — how  un- 
familiar even  the  names  are  beginning  to  sound ! — or  the  chemist  could 
follow  with  critical  judgment  at  least  the  work  of  all  who  were  cultiva- 
ting his  own  broad  field  of  science,  and  a  single  scientific  association, 
such  as  ours,  could  unite  all  of  the  workers  in  the  natural  and  physical 
sciences  into  a  relatively  homogeneous  and  compact  group,  supply  their 
needs  for  intercourse  with  each  other  and  furnish  a  comprehending 
audience  for  presentation  of  the  results  of  scientific  investigation. 
To-day  no  man  of  science  can  pretend  to  follow  all  of  the  work  even  in 
his  own  department,  and  the  investigator  more  often  than  not  must 
seek  an  audience  capable  of  critical  understanding  and  discussion  of  his 
studies  in  a  society  of  biological  chemists,  or  of  experimental  zoologists, 
or  of  plant  pathologists,  or  of  dairy  bacteriologists,  or  whatever  may  be 
the  body  which  represents  his  own  particular  corner  of  science. 

We  may  regret  the  loss  of  many  charming  features  which  have  been 
erased  from  the  landscape  of  science  by  all  of  this  minute  specialization, 
of  which  no  one  can  foresee  the  end,  but  such  a  sentiment  is  much  the 
same  and  as  unavailing  as  that  for  the  return  of  the  days  of  the  stage- 
coach. The  great  instruments  of  progress  in  modern  life — steam  and 
electricity  in  the  industries,  subdivision  of  labor  and  increasing  special- 
ization in  science — are  not  altogether  lovely,  but  they  are  the  conditions 
of  advancement  in  material  prosperity  and  natural  knowledge. 

A  necessary  expression  of  the  changed  conditions  of  modern  science 

^Address  of  the  retiring  president  of  the  American  Association  for  the 
Advancement  of  Science,  delivered  at  the  meeting  in  Chicago,  December  30, 
1907.    Published  in  Science,  January  10,  1908. 

143 


144  MEDICAL   BESEAECH   AND   EDUCATION 

has  been  the  rapid  formation  of  more  and  more  highly  specialized 
societies,  which,  it  must  be  admitted,  meet  the  personal  needs  of  many 
individual  workers  more  fully  than  a  general  association,  representative 
of  all  the  natural  sciences,  can  possibly  do.  But  the  horizon  of  a  man 
of  science  must  indeed  be  narrowly  circumscribed,  if  he  can  not  look 
beyond  what  he  conceives  to  be  his  personal  needs  and  the  little  plot  of 
ground  which  he  cultivates  to  those  necessities  of  science  as  a  whole 
which  an  organization  such  as  ours  is  designed  to  serve.  The  common 
interests  of  science  grow  with  its  expansion,  and  the  more  minute  and 
specialized  its  subdivision,  the  greater  the  need  of  an  association  repre- 
sentative of  these  common  interests — a  central,  national  organization 
which  shall  keep  to  the  front  the  essential  unity  of  all  the  sciences  of 
nature  and  of  man,  and  the  vital  importance  to  the  welfare  of  the 
community  of  the  extension  and  application  of  scientific  knowledge  in 
all  directions. 

In  order  to  serve  most  efficiently  these  common  interests  of  science 
the  central  organization  requires  from  time  to  time  readjustment  in 
details  of  plan  and  working  to  changed  conditions  resulting  from  the 
development  of  science  and  national  growth,  but  its  underlying  purpose 
remains  always  the  same.  This  purpose  is  so  fundamentally  important 
that  its  attainment  in  the  fullest  measure  possible  by  this  association 
should  secure  the  personal  service,  the  active  interest  and  the  zealous 
loyalty  of  all  scientific  workers  and  lovers  of  science  in  this  country. 
The  association  becomes  a  living  organism  through  the  devotion  of  its 
members  to  its  interests  and,  when  fired  by  this  breath  of  life,  the 
machinery  of  organization,  otherwise  inert,  is  made  a  powerful  instru- 
ment for  the  advancement  of  science.  Gratifying  as  has  been  the  growtli 
of  the  association  in  recent  years  in  membership  and  usefulness,  no  one 
will  claim  that  it  has  taken  full  possession  of  its  rightful  heritage.  The 
membership  of  the  association  should  be  doubled,  yes  trebled,  to  secure 
needful  additions  to  its  resources  and  influence.  The  time  is  near,  if 
it  has  not  already  arrived,  when  the  association  urgently  needs  a  central 
office  and  the  services  of  an  executive  officer  and  secretary  sufficiently 
recompensed  to  enable  him  to  devote  his  main  time,  thought  and 
energies  to  the  perfection  of  the  organization,  to  the  extension  of  mem- 
bership, to  the  voluminous  correspondence,  to  the  arrangements  for  the 
meetings  and  to  other  manifold  interests  of  the  association.  Familiarity 
with  the  benefits  which  such  an  arrangement  has  secured  for  the  medical 


MEDICINE    AND    OTHER    SCIENCES    OF    NATUEE  145 

profession  through  the  remarkably  effective  reorganization  within  recent 
years  of  the  American  Medical  Association  leads  me  to  place  the  first 
emphasis  npon  this  direction  of  improvement  for  the  organization  of 
science. 

In  speaking,  as  I  have  done,  of  modern  science  as  subdivided  and 
specialized,  in  order  to  indicate  some  of  the  problems  relating  to  the 
organization  of  this  association,  there  is  danger  of  giving  a  false  im- 
pression to  those  not  fully  informed  of  the  actual  conditions  of  science. 
In  truth,  the  boundaries  between  the  divisions  and  subdivisions  of  the 
sciences  are  being  rapidly  effaced  by  a  deeper  insight  into  the  nature 
and  phenomena  of  the  material  universe.  Natural  science  has  been 
compared  to  a  continent  separated  into  kingdoms,  but  a  more  appro- 
priate comparison,  it  seems  to  me,  is  to  the  spectrum  composed  of  dif- 
ferent rays  which  merge  imperceptibly  into  each  other  and  combine  into 
one  white  light  with  radiant  energy  to  be  discovered  beyond  the  limits 
of  the  visible. 

Who  will  undertake  in  these  days  of  physical  chemistry  to  separate 
the  domain  of  the  physicist  from  that  of  the  chemist?  The  problems 
of  the  geologist  have  long  been  recognized  as  essentially  physical  and 
chemical  in  their  nature.  An  ever  larger  part  of  the  biological  sciences, 
including  the  medical,  is  opening  to  exploration  and  conquest  by  physical 
and  chemical  methods.  To  mathematics  belongs  the  primacy,  for  the 
exactness  of  a  science  is  in  direct  ratio  to  the  degree  with  which  its 
subject-matter  can  be  investigated  by  measurement  and  calculation,  that 
is  by  mathematical  methods.  The  ideal  thus  implied  has  been  fully 
attained  only  by  celestial  mechanics,  but  it  is  approached  by  some  other 
departments  of  physics.  It  is  in  accord  with  this  ideal  that  Priestley 
admirably  said  that  the  object  of  science  is  "  to  comprehend  things 
clearly  and  to  comprise  as  much  knowledge  as  possible  in  the  smallest 
compass."  The  ultimate  problems  of  reality  and  of  knowledge  belong 
to  metaphysics  which  we  may,  following  Descartes,  bury  deep  in  the 
soil  as  the  root  of  the  tree  of  science. 

While  this  mutual  dependence  of  all  the  sciences  of  nature,  so  signi- 
ficant of  the  operation  everywhere  of  common  principles  and  forms  of 
energy  and  of  an  underlying  uniformity  in  the  order  of  nature,  both 
animate  and  inanimate,  is  closest  between  the  physical  sciences  in  the 
restricted  sense,  it  is  strikingly  illustrated  in  the  history  of  the  biological 
sciences,  and  it  has  seemed  to  me  that  the  consideration  of  certain 
11 


146  MEDICAL   BESEABCE   AND   EDUCATION 

aspects  of  the  interdependence  of  that  department  of  biological  science 
with  which  I  am  most  familiar  and  the  other  sciences  of  nature  would 
be  an  appropriate  theme  for  an  address  by  a  representative  of  the  science 
of  medicine  upon  this  occasion.  It  is  to  be  understood  that  under  the 
sciences  of  nature  I  include  those  of  inanimate  nature,  the  physical 
sciences,  as  well  as  those  of  organized  beings,  and  indeed  I  shall  dwell 
more  particularly  upon  relationships  between  the  medical  sciences  and 
physics  and  chemistry,  for  the  points  of  contact  between  the  various 
branches  of  biological  science  and  medicine  are  self-evident  and  more 
familiar. 

It  need  hardly  be  said  that  any  systematic  and  full  consideration 
of  this  broad  theme  far  transcends  the  limits  of  an  address  and  that  in 
selecting  particular  aspects  of  the  subject  and  certain  illustrations  I 
am  quite  aware  that  other  points  of  view  and  other  examples  will  come 
to  the  minds  of  my  hearers  as  equall}'^,  if  not  more,  worthy  of  presenta- 
tion. Medicine  has  derived  such  inestimable  benefits  from  the  physical 
and  natural  sciences  that  I  desire  to  lay  some  emphasis  upon  the 
services  which  it  has  rendered  to  them.  For  my  present  purpose  it  is 
not  necessary  to  assign  any  limits  to  the  operation  of  physical  and 
chemical  laws  in  living  beings,  for  the  most  extreme  vitalist  must  leave 
so  large  a  part  of  the  phenomena  of  living  beings  under  the  subjection 
of  these  laws  that  their  application  in  medical  and  biological  studies 
must  always  be  of  the  highest  importance. 

An  historical  sketch,  necessarily  brief  and  inadequate,  of  some  of  the 
principal  phases  in  the  reciprocal  relations  between  medicine  and  the 
physical  sciences,  up  to  the  time  when  the  latter  became  fully  inde- 
pendent at  the  close  of  the  seventeenth  century,  will  show  with  what 
propriety  medicine  has  been  called  the  "  mother  of  the  sciences." 

Physical  science  has  derived  from  the  Greeks  no  such  extensive 
records  of  sound  observation  and  experience  as  those  which  medicine  has 
inherited  from  the  writings  of  Hippocrates  and  his  followers.  Physical 
theories  embodied  in  the  speculations  of  the  nature-philosophers  con- 
cerning the  constitution  and  properties  of  matter  furnished  the  starting 
point  for  the  Hippocratic  doctrine  of  the  four  humors  and  other  gen- 
eralizations, but  these  theories  sat  so  lightly  upon  Hippocrates  that  his 
name  is  attached  to  that  method  of  medical  study  which  rejects  dogma, 
authority  and  speculation  and  confines  itself  to  the  observation  and 
record  of  clinical  facts.     As  Gomperz  in  his  admirable  work  on  the 


MEDICINE    AND    OTBEE    SCIENCES    OF   NATURE  147 

"  Greek  Thinkers  "  has  clearly  pointed  out,  the  age  of  enlightenment  in 
scientific  thought  was  inaugurated  by  Hippocrates  and  his  medical 
contemporaries. 

The  influence  of  physical  theories  upon  medical  thought  in  antiquity 
can  be  traced  not  only  in  the  humoral  doctrines  of  Hippocrates  and  of 
Galen,  but  also  in  rival  schools,  and  especially  in  the  so-called  methodic 
school  founded  upon  the  atomistic  philosophy  of  Democritus,  which  is 
so  interesting  in  the  history  of  scientific  theories.  As  this  school  pro- 
duced such  admirable  physicians  as  Asclepiades,  Soranus  and  Aretaeus 
it  is  to  be  regretted  that  their  solidistic  pathology  was  so  completely 
displaced  by  the  authority  of  Galen. 

The  large  body  of  medical  knowledge  and  doctrine  which  had 
grown  up  during  the  six  centuries  since  Hippocrates  was  further  de- 
veloped and  fixed  by  Galen  at  the  end  of  the  second  century  after  Christ 
into  a  system  not  less  complete  in  its  field,  nor  less  satisfying  to  the 
minds  of  men  for  nearly  fifteen  centuries,  nor  scarcely  less  remarkable 
as  a  product  of  the  human  mind  than  the  physical  and  philosophical 
systems  of  Aristotle.  "Within  their  respective  spheres  the  system  of 
doctrine  of  each  of  these  great  men  has  exerted  a  similar  dominating 
influence  upon  human  thought  and  has  met  a  similar  fate  through 
influences  almost  identical. 

Although  the  contributions  of  the  Greeks  to  mathematics  were  of  the 
highest  order,  and  the  names  of  Aristarchus,  Eratosthenes,  Hipparchus 
and  Ptolemy  attest  the  great  debt  of  astronomy  to  the  school  of  Alex- 
andria, and  Archimedes  had  founded  one  branch  of  mechanics,  and  the 
works  of  Aristotle  on  "  the  history  "  and  on  "  the  parts  of  animals  " 
entitle  him  to  be  called  the  "  father  of  zoological  science,"  I  think  that 
it  is  safe  to  say  that  the  largest  body  of  ordered  natural  knowledge 
in  any  single  domain  bequeathed  by  the  ancients  to  posterity  was 
represented  by  medicine.  The  botanists  trace  the  beginnings  of  their 
science  to  the  physicians,  Theophrastus  and  Dioscorides,  but  botany  was 
then,  as  it  long  remained,  an  integral  part  of  pharmacy. 

As  medicine,  practically  in  the  shape  in  which  it  left  the  hands 
of  Galen,  continued  for  many  centuries  to  be  the  shelter  for  most  of  the 
natural  sciences,  it  is  worth  considering  how  worthy  a  home  it  furnished. 
For  this  purpose  it  is  not  necessary  to  enter  into  details  of  doctrine  or 
even  the  state  of  existing  knowledge.  A  few  words  concerning  the  gen- 
eral scope  and  spirit  of  medicine,  as  conceived  and  transmitted  by  the 
Greek  physicians,  must  suffice. 


148  MEDICAL   BESEABCH    AND    EDUCATION 

Gomperz  formulates  the  ideal  of  these  physicians  as  regards  their 
conception  of  the  relation  of  medicine  to  the  philosophy  of  nature  in 
these  words : 

The  human  being  is  a  part  of  the  whole  of  nature,  and  can  not  be  under- 
stood without  it.  What  is  wanted  is  a  satisfactory  general  view  of  the  process 
of  the  universe.  Possessing  this,  we  shall  find  the  key  in  our  hand  which  will 
open  the  most  secret  recesses  of  the  art  of  medicine. 

Certainly  such  an  enlightened  conception  of  the  relations  of  medi- 
cine, however  unattainable  it  may  be,  is  broad  enough  to  provide  wel- 
come lodging  under  the  roof  of  the  healing  art  to  any  additions  to  the 
knowledge  of  nature.  Although  priestly  and  magic  medicine  and 
charlatanry  existed  then  by  the  side  of  rational  medicine,  as  they  have 
always  done,  the  Galenic  system,  which  was  a  development  of  the  Hip- 
pocratic,  was  in  essence  observational  and  inductive,  mainly  physical, 
as  distinguished  from  vitalistic,  and  nearly  devoid  of  superstition  and 
the  supernatural.  Galen  conceived  medicine  as  a  science  and  constituted 
anatomy  and  physiology  its  basis.  He  himself  made  valuable  use  in 
his  physiological  studies  of  the  method  of  experiment,  the  singular  and 
almost  unaccountable  lack  of  which  is  largely  responsible  for  the  fan- 
tastic,  though  often  singularly  prophetic,  ideas  and  the  sterility  of  the 
Greek  natural  philosophers  as  contributors  to  natural  knowledge. 
Although  later  cultivators  of  the  domain  of  medicine  followed  far 
behind  these  ideals  of  Greek  medicine,  there  survived  enough  of  their 
spirit  to  enable  us  to  understand  why  the  sciences  of  nature  were  for 
so  long  a  time  fostered  within  this  domain,  which  furnished  them  a 
fitting  and  no  unworthy  abode  until  they  were  strong  enough  to  build 
their  own  homes. 

Although  the  Byzantine,  Arabic  and  medieval  periods  afford  a 
number  of  interesting  illustrations  of  my  theme,  I  shall  not  take  time 
to  consider  them,  for  these  periods  were  relatively  unproductive  for  most 
of  the  sciences  as  well  as  for  medicine.  It  may  be  noted,  however,  that 
the  majority  of  the  names  which  appear  in  the  histories  of  the  various 
natural  sciences  fox  these  times  figure  also  in  the  history  of  medicine. 

The  great  awakening  of  western  Europe,  marked  by  the  revival  of 
learning  and  the  reformation,  stirred  the  long  dormant  spirit  of  inquiry 
and  led  to  revolt  against  authority,  a  fresh  outlook  upon  a  wider  world, 
the  study  of  original  sources,  the  questioning  of  nature  at  first  hand  and 
the  search  for  new  knowledge  in  all  her  kingdoms.  The  seat  of  learn- 
ing was  transplanted  from  the  cloisters  to  the  universities,  which  multi- 


MEDICINE    AND    OTHER    SCIENCES    OF    NATURE  149 

plied  and  flourished  in  the  sixteenth  and  seventeenth  centuries  as  never 
before. 

For  medicine  and  the  sciences  of  nature  the  fire  was  kindled  and 
for  two  centuries  burnt  brightest  in  the  universities  of  northern  Italy. 
Here  the  science  of  human  anatomy  was  reformed  and  marvelously 
developed  by  Vesalius  and  an  illustrious  line  of  successors  in  the  six- 
teenth century,  and  from  this  period  onward  anatomy  never  ceased  to 
be  taught  by  practical  dissection,  that  is  to  say,  by  the  method  of  the 
laboratory.     It  deserves  to  be  emphasized  that  for  over  two  hundred 
and  fifty  years  human  anatomy  was  the  only  subject  taught  in  the 
universities  by  the  laboratory  method  and  that  it  thereby  acquired  a 
commanding  position  in  the  study  of  medicine.     Bearing  in  mind  the 
exceptional  educational  value  thus  imparted  to  the  study  of  anatomy 
and  that  for  a  long  time  medicine  was  the  only  technical  subject  taught 
in  the  universities,  we  can  not  doubt  that  under  conditions  existing 
previous  to  the  nineteenth  century  the  study  of  medicine  furnished  the 
best  available  training  for  the  pursuit  of  any  branch  of  natural  science. 
Prom  his  practical  anatomical  work  the  student  could  acquire  the  habit 
of  close  observation,  manual  dexterity  and  the  sense  for  form  in  nature, 
and  learn  that  real  knowledge  comes  only  from  personal  contact  with 
the  object  of  study.     The  term  "  comparative  anatomy,"  even  if  it 
serves  no  other  useful  purpose,  at  least  points  to  the  historical  fact  that 
human  anatomy  was  the  starting  point  and  basis  of  comparison  for  the 
morphological  study  of  the  lower  animals. 

In  the  sixteenth  century  practically  all  of  the  valuable  contributions 
to  botany  and  to  zoology  were  made  by  physicians,  so  that  natural  history 
scarcely  existed  apart  from  medicine.  Of  the  medical  contributors  to 
botany  it  must  suffice  to  mention  the  names  of  Brunfels,  Fuchs,  Do- 
doens,  Gesner  and  above  all  Cesalpinus,  who  has  been  called  "  the 
founder  of  modern  scientific  botany,"  the  most  important  name  before 
John  Eay  in  the  history  of  systematic  botany,  and  a  distinguished  figure 
likewise  in  medical  history.  Of  names  associated  with  the  history  of 
zoology  in  this  century  the  most  important  are  those  of  the  physicians, 
Conrad  Gesner,  a  marvel  of  encyclopedic  learning,  and  Aldrovandi,  who 
ranks  with  the  founders  of  modern  zoology  and  comparative  anatomy; 
of  lesser  lights  Edward  Wotton  may  be  singled  out  for  mention  as 
the  pioneer  English  zoologist.  He  was  doctor  of  medicine  of  Padua 
and  of  Oxford,  president  of  the  Eoyal  College  of  Physicians,  and  physi- 
cian to  Henry  VIII. 


150  MEDICAL   BESEABCE   AND    EDUCATION 

A  name  of  the  first  rank  in  the  history  of  science  is  that  of  the 
physician,  Georg  Agricola,  who  founded  before  the  middle  of  the  six- 
teenth century  the  science  of  mineralogy  and  developed  it  to  a  state 
where  it  remained  for  nearly  two  hundred  years  without  important 
additions.  I  may  here  remark  in  passing  that  the  first  American  chair 
of  mineralogy  was  established  in  1807  in  the  College  of  Physicians  and 
Surgeons  of  New  York  and  was  occupied  by  Dr.  Archibald  Bruce,  a 
name  familiar  to  mineralogists,  the  founder  of  the  first  purely  scientific 
journal  in  this  country,  the  American  Journal  of  Mineralogy,  which  was 
the  immediate  predecessor  of  Silliman's  American  Journal  of  Science. 

The  difficult  step  from  Hippocrates  and  Galen  to  Euclid  and 
Archimedes  was  surmounted  by  several  physicians  of  the  sixteenth  cen- 
tury, as  it  has  also  been  repeatedly  in  later  times.  The  reader  of  Don 
Quixote  will  recall  that  as  late  as  the  seventeenth  century  the  physician 
was  also  called  "  algehrista  "  in  Spain,  a  survival  of  a  Moorish  designa- 
tion— and  the  sixteenth-century  physicians  Geronimo  Cardano,  as 
extraordinary  a  figure  in  the  history  of  medicine  as  in  that  of  mathe- 
matics, and  Eobert  Eecorde,  the  author  of  the  first  treatise  on  algebra 
in  the  English  language,  exemplified  the  union  of  the  healing  art  with 
the  pursuit  of  mathematics  as  strikingly  as  did  the  Sedbergh  surgeon, 
John  Dawson,  in  the  latter  part  of  the  eighteenth  century,  who  had 
eight  senior  wranglers  among  his  pupils  and  was  one  of  the  few  British 
analysts  of  the  period  who  could  follow  the  work  of  the  great  con- 
temporary, continental  mathematicians.  It  may  here  be  mentioned  that 
of  the  celebrated  Bernoulli  family  of  mathematicians,  two  of  the  most 
distinguished,  John  and  Daniel,  were  doctors  of  medicine,  the  latter 
being  for  a  time  professor  of  anatomy  and  botany  at  Basel. 

The  student  of  medical  history,  who  takes  up  a  history  of  physics, 
such  as  that  of  Eosenberger,  will  probably  be  surprised  to  find  how 
many  of  the  contributors  to  the  latter  subject  in  the  sixteenth  century 
were  physicians  and  that  among  these  are  such  old  friends  as  Fernel  and 
Fracastorius,  whom  he  has  identified  so  intimately  with  the  annals  of 
his  profession.  It  is  to  be  presumed  that  he  already  knew  that  the 
most  famous  of  all,  Copernicus,  was  a  doctor  of  medicine  of  Padua  and 
practised  the  medical  art  gratuitously  among  the  poor  in  Frauenburg. 
.  Far  more  important  for  the  subsequent  history  of  science  than  any 
relations  between  medicine  and  physics  at  this  period  was  the  union 
between  medicine  and  chemistry  effected  by  Paracelsus  and  strengthened 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  151 

by  van  Helmont  and  Sylvius  in  the  following  century,  a  union  so  inti- 
mate that  for  nearly  a  century  and  a  quarter  chemistry  existed  only  as  a 
part  of  medicine  until  freed  by  Eobert  Boyle  from  bonds  which  had 
become  galling  to  both  partners.  The  story  of  this  iatro-chemical 
period,  as  it  is  called,  has  been  told  by  Ernst  von  Meyer  in  his 
fascinating  "  History  of  Chemistry  "  in  a  way  not  less  interesting  to 
the  student  of  medicine  than  to  that  of  chemistry,  and  should  be  there 
read  by  both. 

In  reply  to  the  question  what  benefit  accrued  to  both  medicine  and 
chemistry  from  their  mutual  interaction  during  this  period  von  Meyer 
says: 

The  answer  is,  a  mutual  enrichment,  which  did  almost  more  for  chemistry 
than  for  medicine;  for  the  former  was  raised  to  a  higher  level  through  being 
transferred  from  the  hands  of  laboratory  workers,  who  were  mostly  uneducated, 
to  those  of  men  belonging  to  a  learned  profession  and  possessing  a  high  degree 
of  scientific  culture.  The  iatrochemical  age  thus  formed  an  important  period 
of  preparation  for  chemistry,  a  period  during  which  the  latter  so  extended  her 
province  that  she  was  enabled  in  the  middle  of  the  seventeenth  century  to  stand 
forth  as  a  young  science  by  the  side  of  her  elder  sister,  physics. 

Paracelsus  in  carrying  out  his  program  that  "  the  object  of  chem- 
istry is  not  to  make  gold  but  to  prepare  medicines  "  made  the  phar- 
macist's shop  a  chemical  laboratory  and  until  the  establishment  of 
laboratories  by  Thomas  Thomson  and  by  Liebig  in  the  first  quarter  of 
the  nineteenth  century  this  continued  to  be  the  only  kind  of  laboratory 
available  for  practical  training  in  chemistry.  Through  this  portal  en- 
tered into  the  domain  of  chemistry  Lemery,  Kunkel,  Marggraf,  Klap- 
roth,  Scheele,  Proust,  Henry,  Dumas  and  many  others.  Liebig,  who 
also  began  as  an  apothecary's  pupil,  has  graphically  described  these 
conditions. 

That  strange,  iconoclastic  genius,  Paracelsus,  typifies,  as  no  other 
name  in  science,  the  storm  and  stress,  the  strife,  the  intellectual  rest- 
lessness and  recklessness  of  the  sixteenth  century  which  prepared  the 
way  for  the  glorious  light  of  science  which  illuminated  the  following 
century.  With  boundless  enthusiasm  minds,  now  fully  liberated  from 
the  bondage  of  authority,  entered  upon  new  paths  of  philosophical 
thought  and  scientific  discovery  and  achieved  triumphs  unequaled  even 
in  the  nineteenth  century.  The  great  achievement  was  the  full  recogni- 
tion and  the  fruitful  application  of  the  true  method  of  science  in  all  its 
completeness. 

Although  isolated  and  limited  use  had  been  made  of  the  method  of 


152  MEDICAL   BESEABCH   AND   EDUCATION 

experiment  in  former  times — I  have  already  cited  Galen  and  I  might 
have  added  physicians  of  the  Alexandrine  school — the  real  birth  of  ex- 
perimental science  was  toward  the  end  of  the  sixteenth  and  the  beginning 
of  the  seventeenth  centuries.  Medicine  can  hardly  be  said  to  have 
presided  at  this  birth,  but  its  influence  was  not  absent.  Galileo  was  a 
student  of  medicine,  one  of  his  teachers  being  the  celebrated  physician 
and  botanist,  Cesalpinus,  when  in  1583  he  watched  the  great  bronze 
lamp  swinging  before  the  high  altar  of  the  Cathedral  of  Pisa,  and  I 
question  whether  it  would  have  occurred  to  any  one  without  some  in- 
terest in  medicine  to  determine  the  isochronism  of  the  pendulum  by 
counting  the  beats  of  the  pulse.  It  seems  improbable  that  without 
his  medical  training  Galileo  would  have  made  the  measurement  of  the 
pulse  the  first  application  of  the  new  principle  and  have  called  the 
instrument  the  pulsilogon.  Nevertheless  we  must  bear  in  mind  that 
natural  philosophers  of  this  period  and  throughout  the  seventeenth  cen- 
tury were  greatly  interested  in  anatomy  and  physiology.  Dr.  Weir 
Mitchell  in  an  address,  as  charming  as  it  is  erudite,  has  called  attention 
to  interesting  observations  of  Kepler  on  the  pulse,  which  the  great 
astronomer  believed  to  have  some  relation  to  the  heavenly  motions,  in 
this  and  certain  ather  views  exemplifying,  as  some  modern  physicists 
have  done,  the  compatibility  of  a  firm  hold  of  positive  scientific  truth 
with  an  irresistible  tendency  to  mysticism  and  occult  science,  Kepler 
was  not,  as  has  been  stated,  the  first  actually  to  count  the  pulse,  for 
we  read  that  as  long  ago  as  the  Alexandrine  period  Herophilus  timed 
the  pulse  with  a  water-clock. 

But  if  Galileo  was  only  half  a  doctor  of  physic,  as  Dr.  Mitchell  calls 
him,  his  elder  contemporary,  William  Gilbert,  second  in  importance  only 
to  Galileo  among  the  creators  of  experimental  science,  the  founder  of 
the  science  of  magnetism  and  a  significant  name  in  the  history  of  elec- 
tricity, was  fully  identified  with  the  profession,  being  the  most  dis- 
tinguished English  physician  as  well  as  man  of  science  of  his  day, 
physician  to  both  Queen  Elizabeth  and  James  I.,  and  president  of  the 
Eoyal  College  of  Physicians. 

Galileo's  younger  contemporary,  William  Harvey,  the  discoverer  of 
the  circulation  of  the  blood,  occupies  in  the  history  of  experimental 
science  an  independent  position,  quite  unlike  that  of  the  other  experi- 
mental physiologists  of  the  century.  These  other  physicians,  as  Sanc- 
torius,    Borelli,    Lower,    Mayow,    consciously    took    possession   of    the 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  153 

method  of  experiment  as  a  powerful  and  newly  discovered  instrument  of 
research  and  were  swayed  in  all  their  physiological  work  by  the  dis- 
coveries of  the  physicists.  Not  so  Harvey,  who  was  influenced  but  little 
by  contemporary  physical  science  and  is  linked  on,  not  to  Galileo  or  to 
Gilbert,  as  exemplars  of  experimentation,  but  in  a  very  direct  way  to 
the  experimental  physiologist,  Galen,  and  to  Aristotle,  as  well  as  to  the 
Italian  anatomists  of  the  preceding  century.  Harvey's  genuinely  scien- 
tific mind  was  in  greater  s}Tnpathy  with  Aristotle  than  with  the  essen- 
tially unscientific  Lord  Bacon,  who  was  his  patient  and  of  whom  he 
said,  "  He  writes  philosophy  like  a  Lord  Chancellor." 

There  is  no  more  striking  characteristic  of  seventeenth-century 
science  than  the  wide  range  of  inquiry  covered  by  individual  investi- 
gators. The  natural  sciences  were  no  longer  apprenticed  to  medicine, 
after  Boyle  had  liberated  chemistry,  but  the  problems  of  anatomy,  of 
physiology  and  even  of  practical  medicine  were  not  separated  from  those 
of  the  natural  philosopher  and  of  the  naturalist.  "With  unparalleled 
versatility  every  one  seemed  to  roam  at  will  over  the  whole  domain  of 
knowledge  and  thought.  How  they  leaped  and  tumbled  in  the  virgin 
fields  and  hied  "  to-morrow  to  fresh  woods  and  pastures  new  " ! 

Descartes  was  an  anatomist  and  physiologist  as  well  as  philosopher, 
mathematician  and  physicist,  and  John  Locke,  the  other  great  liberator 
of  thought  in  this  century,  was  educated  in  medicine,  practised  it  and, 
like  Boyle,  accompanied  Sydenham  on  his  rounds.  Kepler  studied  the 
pulse,  contributed  to  physiological  optics  and  calculated  the  orbits  of  the 
planets.  Borelli  was  an  important  mathematician,  physicist  and  as- 
tronomer, as  well  as  one  of  the  greatest  physiologists  and  physicians  of 
the  century.  Bartholinus  was  also  professor  of  mathematics  as  well  as 
of  medicine,  and  discovered  the  double  refraction  of  Iceland  spar.  His 
even  more  remarkable  pupil,  Steno,  left  a  name  memorable  in  geology 
and  paleontology  as  well  as  in  anatomy  and  physiology,  and  died  a 
bishop  of  the  Eoman  Catholic  Church.  Mariotte,  a  pure  physicist, 
discovered  the  blind  spot  in  the  retina.  Boyle  anatomized,  experimented 
on  the  circulation  and  respiration,  started  chemistry  on  new  paths  and 
perpetuated  his  name  in  attachment  to  an  important  physical  law. 
Hooke,  mxost  versatile  of  all,  claimed  priority  for  a  host  of  discoveries, 
and  did  in  fact  explore  nearly  every  branch  of  science  with  brilliant, 
though  often  inconclusive,  results.  Malpighi  was  an  investigator 
equally  great  in  vegetable  and  in  animal  anatomy  and  physiology,  and 


154  MEDICAL   BESEABCE   AND   EDUCATION 

what  a  glorious  time  it  was  for  the  microscopists,  like  Malpighi,  Leeu- 
wenhoek,  Swammerdam  and  others,  who  could  immortalize  their  names 
by  turning  the  new  instrument  on  a  drop  of  muddy  water,  or  blood, 
or  other  fluid,  or  a  bit  of  animal  and  vegetable  tissue !  From  the 
funeral  sermon  upon  Nehemiah  Grew,  practitioner  of  physic  and  one 
of  the  founders  of  vegetable  anatomy  and  physiology,  we  are  assured 
that  he  was  "  acquainted  with  the  theories  of  the  heavenly  bodies,  skilled 
in  mechanicks  and  mathematicks,  the  proportions  of  lines  and  numbers, 
and  the  composition  and  mixture  of  bodies,  particularly  of  the  human 
body"  and  also  "well  acquainted  with  the  whole  body  of  Divinity  and 
had  studied  Hebrew  to  more  proficiency  than  most  divines." 

The  early  proceedings  of  the  various  scientific  societies  and 
academies,  started  in  this  century  and  destined  to  become  powerful 
promoters  of  science,  afford  excellent  illustrations  of  the  wide  scope  of 
scientific  inquiry.  A  quotation  from  the  narrative  of  the  famous 
mathematician.  Dr.  Wallis,  gives  further  evidence  of  the  position  of 
the  medical  and  other  sciences  in  the  aims  and  work  of  the  little  band 
of  thoughtful  students  of  nature  who  assembled  in  Oxford  in  1645  and 
later  in  London,  constituting  the  so-called  invisible  college,  which  grew 
into  the  Royal  Society.     He  says : 

Our  business  was  (precluding  matters  of  theology  and  state  affairs)  to  dis- 
course and  consider  of  philosophical  enquiries  and  such  as  related  thereto: — aa 
Physick,  Anatomy,  Geometry,  Astronomy,  Navigation,  Staticks,  Magneticks, 
Chymicks,  Mechanicks  and  Natural  Experiments;  with  the  state  of  these  studies 
and  their  cultivation  at  home  and  abroad.  We  then  discoursed  of  the  circula- 
tion of  the  blood,  the  valves  in  the  veins,  the  venae  lacteae,  the  lymphatic  vessels, 
the  Copernican  hypothesis,  the  satellites  of  Jupiter,  the  oval  shape  (as  it  then 
appeared)  of  Saturn,  the  spots  on  the  sun  and  its  turning  on  its  own  axis,  the 
inequalities  and  selenography  of  the  moon,  the  several  phases  of  Venus  and 
Mercury,  the  improvement  of  telescopes  and  grinding  of  lenses  for  that  purpose, 
the  weight  of  air,  the  possibility  or  impossibility  of  vacuities  and  nature's 
abhorrence  thereof,  the  Torricellian  experiment  in  quicksilver,  the  descent  of 
heavy  bodies  and  the  degree  of  acceleration  therein,  with  divers  other  things 
of  like  nature. 

The  work  and  publications  of  the  small  group  of  physicians  and  men 
of  science  composing  the  Accademia  del  Cimento,  which  was  established 
in  Florence  in  1657  and  flourished  unfortunately  for  only  ten  years, 
exemplify  in  an  equally  striking  manner  the  combination  of  medical 
with  other  scientific  pursuits  and  the  wide  range  of  study. 

Borelli,  the  most  important  member  of  this  academy,  founded  the 
so-called  iatro-physical  school  of  medicine,  which  contested  the  field 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  155 

for  supremacy  with  the  iatro-chemical,  to  which  I  have  already  referred, 
during  the  greater  part  of  the  seventeenth  century.  The  story  of  these 
two  schools  is  epochal  and  occupies  the  larger  part  of  the  history  of 
physic  during  this  century.  Medicine  owes  to  adherents  of  each  school 
a  large  debt  for  important  contributions  to  knowledge  and  fresh  direc- 
tions of  thought.  Where  physical  methods  and  knowledge,  as  they 
then  existed,  were  applicable,  as  in  investigation  of  the  circulation  and 
of  the  action  of  muscles,  the  iatro-physicists  carried  aff  the  palm, 
Borelli's  "  De  motu  animaliuni "  being  one  of  the  medical  classics.  But 
notwithstanding  the  great  inferiority  of  chemistry  to  physics  at  this  time 
the  paths  of  discovery  opened,  although  not  traveled  far,  by  the  iatro- 
chemists  have  led  to  more  important  results.  The  beginnings  of  our 
knowledge  of  digestion  and  of  secretion  and  even  of  the  chemistry  of 
the  blood  and  other  fluids  are  to  be  traced  in  the  main  to  the  iatro- 
chemical  school,  and  the  study  of  fermentation,  although  this  was  not 
conceived  in  the  same  sense  as  to-day,  of  gases,  salts,  acids  and  alkalis 
was  of  importance  to  medicine  as  well  as  to  chemistry. 

There  never  has  been  a  period  in  medical  history,  not  even  in  recent 
years,  when  so  determined  an  effort  was  made  to  convert  medicine  into 
applied  physics  and  chemistry  as  that  in  the  seventeenth  century.  Des- 
cartes's  dualistic  philosophy,  which  left  no  more  room  for  the  inter- 
vention of  other  than  mechanical  forces  in  the  organized  world  than  in 
the  inorganic,  had  great  influence  upon  the  minds  of  physicians  as 
well  as  of  physicists.  Galileo  had  founded,  and  a  line  of  great  experi- 
mental philosophers  from  him  to  Newton  had  vastly  extended,  the  sci- 
ence of  dynamics,  which  then  seemed  to  many,  as  in  potentiality  it  may 
be,  as  applicable  to  all  the  activities  of  living  beings  as  to  the  inani- 
mate universe.  There  came  in  the  first  quarter  of  the  century  the 
greatest  physical  discovery  in  the  history  of  physiology,  that  of  the 
circulation  of  the  blood,  which  opened  the  large  biological  tract  of 
haemodynamics  to  rewarding  study  by  the  new  physical  methods.  The 
balance,  the  pendulum-chronometer,  the  thermometer  and  other  newly 
invented  instruments  of  precision  were  turned  to  good  account  in  an- 
atomical, physiological  and  pathological  investigations,  and  physicians 
began  to  count,  to  weigh,  to  measure,  to  calculate  and  to  discover  a  world 
of  form  and  structure  hidden  from  their  unaided  vision.  Such  chem- 
istry as  existed  was  pursued  almost  exclusively  by  physicians  and 
primarily  in  the  interest  of  medicine. 


156  MEDICAL   BESEAECE   AND   EDUCATION 

What  wonder,  then,  that  physicians  who  came  under  the  influences 
of  this  great  awakening  in  physical  science  and  took  no  small  part  in 
its  advent  and  promotion,  should  have  entertained  hopes,  soon  doomed 
to  disappointment,  of  the  henefits  to  medicine  from  application  of  the 
new  knowledge  and  have  promulgated  hypotheses  and  systems  of  doc- 
trine which  seem  to  us  so  false  and  extravagant!  Great  as  was  the 
advance  in  physical  knowledge,  it  was  utterly  inadequate  for  many  of 
the  purposes  to  which  the  iatro-physicists  and  iatro-chemists  applied  it, 
and  to  this  day  many  of  their  problems  remain  unsolved. 

Grateful  we  should  be  for  valuable  discoveries  and  new  points  of 
view  which  medicine  owes  to  these  men,  often  so  unjustly  criticized, 
but  the  time  had  come  for  men  of  our  profession  to  resume  the 
Hippocratic  method  of  collecting  facts  of  observation  within  their  own 
clinical  field,  and  Sydenham,  of  all  the  physicians  of  his  century  the 
name,  next  to  Harvey's,  most  honored  by  medical  posterity,  in  calling 
out,  "  back  to  Hippocrates ! "  turned  the  face  of  medicine  again  toward 
nature. 

There  are  interesting  points  of  comparison  between  Sydenham's 
position  in  the  history  of  medicine,  and  that  of  his  fellow-countryman 
and  contemporary,^  John  Eay,  in  natural  history.  I  am  sorry  that  my 
profession,  which  has  fostered  so  many  ardent  students  of  nature,  in- 
cluding Linnaeus  and  Agassiz,  the  respective  bi-centenary  and  centenary 
anniversaries  of  whose  birth  have  been  celebrated  with  such  enthusiasm 
in  the  year  now  closing,  can  not  claim  this  greatest  naturalist  of  his 
century.  Both  Sydenham  and  Ray  stood  apart  from  the  great  scientific 
movement  of  their  day;  both,  little  influenced  by  theory  or  tradition, 
concentrated  their  efforts  strictly  within  their  respective  fields  of  ob- 
servation, and  both  introduced  new  methods  of  studying  their  sub- 
jects. As  Eay,  the  plants  and  animals,  so  Sydenham  described  dis- 
eases as  objects  of  nature,  his  discriminations  and  descriptions  being  in 
several  instances  the  first,  and  to  this  day  in  some  cases  unsurpassed 
and  unimpaired  by  new  knowledge.  Like  Eay,  he  was  not  a  mere 
species-monger,  but  he  had  the  synthetic  power  to  assign  the  proper 
place  to  single  observations  and  to  combine  them  into  well-ordered 
groups.  By  way  of  contrast,  the  attempt  of  Linnaeus  to  classify  diseases 
into  species  and  genera,  although  of  some  historical  interest,  was  utterly 
barren,  the  subject-matter  permitting  no  such  method  of  approach  as 
that  which  enabled  this  great  systematist  to  start  a  new  epoch  in 
botany  and  zoology. 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  157 

With  the  close  of  the  seventeenth  century  we  reach  a  dividing  line, 
which  limitations  of  time  compel  me  to  make  on  this  occasion  a  terminal 
one,  in  the  historical  survey  of  the  interrelations  of  medicine  and  the 
natural  sciences.  I  can  not,  however,  refrain  from  at  least  the  bare 
mention  of  the  influence  of  physicians  on  the  development  of  science 
in  America — a  theme  which  I  hope  on  some  other  occasion  to  take  up 
more  fully.  Leonard  Hoar,  doctor  of  medicine  of  Cambridge,  England, 
brought  something  of  the  new  experimental  philosophy  to  America,  and 
during  his  short  incumbency  of  the  presidency  of  Harvard  College 
(1672-1674)  planted  the  first  seeds  of  technical  training  on  American 
soil,  but  too  early  for  them  to  germinate.  Of  much  greater  importance 
was  Cadwallader  Colden,  an  Edinburgh  doctor,  acquainted  with  the 
Newtonian  mathematics  and  physics,  and  a  botanist  of  note  in  his  day, 
who  did  much  to  instil  an  interest  in  physical  and  natural  science  among 
physicians  and  others  in  Philadelphia  and  New  York  in  the  first  half 
of  the  eighteenth  century.  Besides  John  Bartram,  who  studied  and  to 
some  extent  practised  physic,  the  founder  on  the  banks  of  the  Schuyl- 
kill of  the  first  botanical  garden  in  this  country,  there  is  a  long  line 
of  American  medical  botanists,  as  Clayton,  Colden,  Mitchell,  Garden, 
Kuhn,  Wistar,  Hosack,  Barton,  Baldwin,  Bigelow,  Torrey,  the  teacher 
and  collaborator  of  Asa  Gray,  himself  a  graduate  in  medicine,  Engel- 
mann,  whose  names  are  perpetuated  in  genera  of  plants,  and  many 
others  up  to  this  day.  Until  the  coming  of  Agassiz,  who  trained  many 
who  did  not  enter  medicine  (although  among  his  pupils  were  also  not  a 
few  medical  men,  including  the  Le  Contes  and  A.  S.  Packard),  most  of 
the  zoologists  were  also  physicians,  and  Agassiz  found  already  at  work 
in  his  field  in  Boston  the  physicians,  Gould,  Storer,  Harris,  and  one 
worthy  of  a  place  by  his  side,  Jeffries  Wyman.  Of  the  delightful 
naturalist  type  of  physician  there  have  been  many,  such  as  Samuel 
Latham  Mitchell,  John  D.  Godman,  Jared  Kirtland,  and  above  all  a 
man  who  belongs  to  the  world's  history  of  biological  and  paleontological 
science,  Joseph  Leidy,  whose  monument  was  recently  dedicated  in 
Philadelphia.  Geologists  will  call  to  mind  such  names  as  Gibbs,  New- 
berry, John  Lawrence  Smith,  also  a  chemist  and  mineralogist,  and  the 
Le  Contes;  and  ethnologists  the  names  of  Samuel  G.  Morton,  Daniel 
G.  Brinton  and  Edward  H.  Davis.  How  many  of  the  Arctic  explorers 
from  this  country,  as  Kane,  Parry,  Hayes,  Schwatka,  as  well  as  from 
England,  have  been  physicians !     There  have  been  many  whose  interest 


158  MEDICAL   BESEABCH   AND   EDUCATION 

in  science  was  first  awakened  by  the  study  of  medicine,  but  who  were 
not  graduated  as  doctors,  as  Joseph  Henry,  Sears  Cook  "Walker,  Thomas 
Sterry  Hunt  and  Spencer  F.  Baird.  Particularly  interesting  as  in- 
vestigators in  physical  science  were  members  of  the  medical  families 
of  the  Drapers,  the  Le  Contes  and  the  Rogers.  This  bare  mention  of  a 
few  of  the  American  medical  contributors  to  science,  mostly  of  an  earlier 
period,  will  perhaps  afEord  some  indication  of  the  services  of  medicine 
to  scientific  development  in  this  country. 

After  the  seventeenth  century  in  Europe  the  natural  sciences,  though 
often  cultivated  by  those  educated  in  medicine  and  practising  it,  were 
independent  and  followed  their  own  paths,  which,  however,  communi- 
cated by  many  by-ways  with  the  road  of  medicine  and  with  each  other. 

Botany  and  zoology  acquired  their  independent  position  probably 
more  through  the  work  of  Eay  and  Willughby  than  by  that  of  any  other 
naturalist.  Botany,  however,  remained  for  over  a  century  still  mainly 
in  the  hands  of  physicians.  An  interesting  chapter  in  its  history  is  the 
story  of  the  various  apothecaries'  and  other  botanical  gardens  established 
through  the  efforts  of  physicians  and  conducted  by  them  primarily  for 
the  study  of  the  vegetable  materia  medica.  From  such  beginnings  has 
grown  the  Jardin  des  Plantes  in  Paris,  started  by  two  physicians, 
Herouard  and  la  Brosse,  in  1633,  into  the  great  museum  of  natural  his- 
tory made  by  Buffon,  Cuvier  and  others  as  famous  for  the  study  of 
zoology  as  by  Brongiart  and  his  successors  for  botany.  Less  humble 
was  the  foundation  of  the  British  Museum  and  its  appanage,  the  great 
Museum  of  Natural  History  in  South  Kensington,  the  gift  to  the  nation 
of  his  valuable  collections  in  natural  history  and  other  departments  by 
Sir  Hans  Sloane,  a  leading  London  physician  in  the  first  half  of  the 
eighteenth  century. 

Boyle's  name  is  associated  especially  with  the  foundation  of  chem- 
istry as  a  separate  science.  William  Cullen  deserves  to  be  remembered 
in  the  history  of  this  science,  who,  although  not  an  important  con- 
tributor to  chemistry  as  he  was  to  medicine,  was  in  the  second  half  of 
the  eighteenth  century  the  first  to  raise  the  teaching  and  study  of 
chemistry  to  their  true  dignity  in  the  universities  of  Great  Britain,  and 
imparted  the  first  stimulus  to  his  pupil  and  successor  in  the  Edinburgh 
chair  of  chemistry,  William  Black. 

Mechanics,  never  really  dependent  upon  medicine,  was  lifted  by 
Newton  to  analytical  heights,  rarely  scaled  by  disciples  of  ^sculapius. 


MEDICINE    AND    OTHER    SCIENCES    OF   NATUEE  159 

although,  as  Thomas  Young  and  Helniholtz  have  exemplified,  not 
wholly  beyond  their  reach.  But  not  all  of  physics  stands  on  the  lofty 
plane  of  abstract  dynamics  constructed  by  Newton,  Lagrange,  Laplace 
and  Gauss,  the  highest  probably  hitherto  attained  by  the  human  in- 
tellect. There  have  been  many  educated  in  medicine  who  have  made 
notable  contributions  to  the  physics  of  sound,  heat,  light,  magnetism, 
electricity  and  the  general  properties  of  matter  and  energy.  I  have 
collected,  without  any  pretence  to  exhaustiveness,  the  names  of  over  a 
hundred  physicians  or  men  trained  for  the  practise  of  medicine  or 
pharmacy  who  have  made  contributions  to  physics  sufficiently  notable 
to  secure  them  a  place  in  the  history  and  records  of  this  science.  A 
few  of  the  more  important  are  Gilbert,  van  Musschenbroek,  Sir  William 
"Watson,  Black,  Galvani,  Berthollet,  J.  W.  Bitter,  Olbers,  Wollaston, 
Thomas  Young,  Oersted,  Dulong,  Mayer,  Thomas  Andrews,  Sainte- 
Clair  Deville,  the  Drapers,  Foucault,  Helmholtz.  Sir  Humphry  Davy 
literally  sprang  out  of  the  lap  of  medicine  into  the  Eoyal  Institution, 
just  founded  by  Count  Eumford,  who  himself  had  begun  the  study  of 
medicine  before  he  left  his  native  country.  If  the  surgeons  of  England 
at  that  time  had  only  heeded  what  Davy  told  them  concerning  the 
anesthetic  properties  of  nitrous  oxide  gas,  America  would  have  been 
deprived  of  the  greatest  service  which  she  has  rendered  to  medicine. 

In  the  long  line  of  important  physiologists  of  the  past  century  who 
represent  especially  the  physical  direction  of  investigation  in  their  im- 
portant branch  of  medicine  and  biology,  there  are  not  a  few  whose 
names  find  a  place  in  the  histories  of  modern  physics,  as  E.  H.  "Weber, 
Du  Bois  Eeymond,  von  Briicke,  Ludwig,  Fick,  "Vierordt,  Poiseuille  and 
others,  and  the  studies  of  the  botanists,  Pfeffer  and  de  "Varies,  on  the 
turgor  of  vegetable  cells  opened  an  important  field  of  physical  chemistry. 

Aspects  of  my  subject,  full  of  interest,  which  I  can  now  barely  touch 
upon,  are  the  influence  of  previous  medical  or  biological  training  upon 
the  work  of  a  physicist  or  chemist,  and  closely  connected  with  this  the 
extent  to  which  purely  physical  problems  have  been  approached  from  the 
biological  side.  Call  to  mind  how  the  central  physical  and  chemical 
problem  of  the  eighteenth  century,  the  nature  of  combustion,  was 
throughout  this  period  intimately  associated  with  the  kindred  physio- 
logical problem  of  respiration,  and  how  John  Mayow  in  the  seventeenth 
century,  approaching  the  subject  from  the  biological  side,  reached  a  con- 
clusion in  accord  with  that  fully   demonstrated   a  century  later  by 


160  MEDICAL   BESEAECE   AND    EDUCATION 

Lavoisier,  who  thereby  opened  a  new  era  for  physiology  as  well  as  for 
chemistry.  For  the  first  time  clear  light  was  shed  upon  the  function  of 
respiration,  the  nature  of  metabolism  and  the  sources  of  animal  heat, 
and  such  physical  interest  was  attached  to  the  study  of  these  physio- 
logical phenomena  that  physicists  of  the  rank  of  Laplace,  in  association 
with  Lavoisier,  Dulong,  W.  E.  Weber,  Magnus,  A.  C.  Becquerel,  Hirn, 
Eegnault,  and  of  course  Helmholtz,  have  all  made  valuable  contributions 
to  the  elucidation  of  these  subjects. 

The  study  of  electricity,  especially  after  the  physiologist,  Galvani's 
epochal  discovery,  more  correctly  interpreted  by  Volta,  engaged  the 
attention  of  physicians  and  physiologists  scarcely  less  than  that  of 
physicists.  The  latter  became  greatly  interested  in  animal  electricity, 
a  subject  partly  cleared  up  by  the  physicists,  Eitter  and  Nobili,  but 
mainly  by  the  physiologist,  Du  Bois  Eeymond.  Ostwald  points  out,  as 
a  matter  of  interest  in  the  history  of  the  human  mind,  that  the  physician 
Soemmering  was  led  to  conceive  of  the  transmission  of  intelligence  by 
electricity  from  analogy  with  the  conveyance  of  impulses  by  the  nerves, 
and  thus  to  invent  his  practically  useless  form  of  the  electric  telegraph. 
However  fanciful  such  a  relationship  may  be,  it  is  interesting,  as  Sir 
David  Brewster  discovered,  that  the  first  proposal  for  an  electric  tele- 
graph worked  by  statical  electricity  was  made  and  actually  carried  into 
efEect  as  early  as  1753  by  the  Greenock  surgeon,  Charles  Morrison.  It 
is  now  well  understood  that  no  one  has  the  sole  credit  of  inventing  the 
electric  telegraph,  the  idea  of  which  was  implicit  in  Stephen  Gray's 
observation  in  1727  of  the  transmission  of  electricity  by  a  wire. 

Of  curious  interest  is  the  introduction  of  electricity  for  the  treat- 
ment of  disease  by  the  physicists,  Kratzenstein,  ISTollet  and  Jallabert, 
shortly  before  the  middle  of  the  eighteenth  century,  who  reported  cures 
by  its  use. 

There  is  no  more  striking  illustration  of  the  correlation  of  two 
apparently  distinct  lines  of  approach  to  the  same  problem  than  the 
attack  from  the  biological  and  from  the  purely  physical  sides  upon  the 
thermodynamic  problem,  which  is  as  fundamental  for  biology  as  for 
physics.  The  conception  of  the  principle  of  conservation  of  energy  was 
supplied  independently  and  almost  simultaneously  on  the  one  hand  by 
students  of  the  conditions  of  mechanical  work  done  by  the  animal 
machine  and  on  the  other  hand  by  investigators  of  technical  machines. 
Much  of  the  essential  preliminary  study  was  on  the  biological  side  by 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  161 

Boyle,  Mayow,  Black  and  Lavoisier.  Mainly  from  the  same  side 
the  physician  and  physicist,  Thomas  Young,  first  formulated  the 
modern  scientific  conception  of  energy  as  the  power  of  a  material  system 
to  do  work.  Davy  and  Eumford  contributed,  and  from  the  physio- 
logical side  Mohr,  Mayer  and  Helmholtz,  and  from  the  purely  physical 
side,  after  preliminary  work  by  Poncelet  and  Sadi-Carnot,  Joule, 
Thomson  and  Clausius  reached  the  same  grand  conception.  The  first 
to  enunciate  clearly  and  fully  the  doctrine  of  the  conservation  of  energy 
and  to  measure  the  unit  of  mechanical  work  derived  from  heat  was  the 
physician,  J.  E.  Mayer.  Joule's  work  completed  the  demonstration, 
but  Mayer's  name  is  deservedly  attached  to  this  principle  by  Poincare 
and  others,  as  Lavoisier's  is  to  that  of  the  conservation  of  mass,  and 
Sadi-Carnot's  to  the  principle  of  degradation  of  energy.  As  regards 
this  last  principle  it  is  almost  as  interesting  to  biologists  as  to  physicists 
that  in  the  so-called  Brunonian  movement,  discovered  by  the  physician 
and  more  eminent  botanist,  Robert  Brown,  and  the  subject  of  interest- 
ing physical  investigations  in  recent  years,  we  behold  an  apparent 
exception  to  the  principle  of  degradation  of  energy,  such  as  Clerk  Max- 
well pictured  as  possible  to  the  operations  of  his  sorting  demon. 

I  must  forego  further  citation  of  examples  of  this  kind  of  correla- 
tion between  the  work  of  physicists  and  of  physiologists,  and  leave 
untouched  the  chemical  side,  which  is  much  richer  in  similar  illustra- 
tions. The  significance  to  organic  chemistry  of  the  synthesis  of  urea 
by  "Wohier,  and  to  agricultural  chemistry  of  the  bacteriological  studies 
of  nitrification  in  the  soil  and  fixation  of  nitrogen  in  plants,  will  perhaps 
indicate  how  large  and  fascinating  a  field  I  must  pass  by. 

The  great  advances  in  physics  and  chemistry  initiated  in  France 
toward  the  end  of  the  eighteenth  and  beginning  of  the  nineteenth  cen- 
tury were  quickly  reflected  upon  the  medical  and  biological  sciences 
through  influences  which  in  large  part  are  attributable  to  this  new 
movement  in  physical  science.  New  methods  of  physical  examination 
of  the  patient  were  introduced,  and  pathology  and  experimental  and 
chemical  physiology  were  developed  as  biological  sciences  of  the  first 
rank.  This  reformation  of  the  medical  sciences  in  the  first  third  of 
the  nineteenth  century  was  mainly  the  work  of  Frenchmen,  the  great 
names  in  this  development  being  those  of  Lavoisier,  Bichat,  Laennec 
and  Magendie,  the  last  a  friend  and  physician  of  Laplace,  and  con- 
temporary of  Cuvier,  who  represented  a  like  movement  in  zoology. 

12 


162  MEDICAL   BESEABCH   AND    EDUCATION 

Liebig,  the  pupil  of  Gay-Lussac  and  founder  of  biological  chemistry  as 
a  distinct  science,  carried  in  the  third  decade  of  the  century  the  new 
spirit  to  Germany,  where  Johannes  Miiller  and  his  pupils  became  the 
center  of  a  movement  which  rescued  medicine  and  biology  from  the 
shackles  of  the  philosophy  of  nature  and  has  given  Germany  the  suprem- 
acy in  these  jBelds  of  science.  The  experimental  physiological  work  of 
the  brothers  "Weber,  two  being  physicians  and  the  third  the  great 
physicist  who  was  so  intimately  associated  with  Gauss  in  Gottingen,  was 
of  great  influence  in  introducing  the  physical  direction  of  physiological 
research,  but  Magendie  stands  first  in  making  the  experimental  method 
the  corner-stone  of  normal  and  pathological  physiology  and  pharma- 
cology. 

Most  pertinent  to  my  theme  is  it  to  note  that  the  light  which  has 
transformed  the  face  of  modern  practical  medicine  came  in  the  first 
instance  not  from  a  physician,  but  from  a  physicist  and  chemist,  Pasteur. 
The  field  of  bacteriological  study  was  placed  on  a  firm  foundation  and 
thrown  open  to  ready  exploration  by  Robert  Koch,  and  thereby  that  class 
of  diseases  most  important  to  the  human  race,  the  infectious,  became 
subject  in  ever-increasing  measure  to  control  by  man.  Thus  hygiene 
and  preventive  medicine,  through  their  power  to  check  the  incalculable 
waste  of  human  life  and  health  and  activities,  have  come  into  relations, 
which  have  only  begun  to  be  appreciated,  with  educational,  political, 
economic  and  other  social  sciences  and  conditions,  and  with  the  admin- 
istration of  national,  state  and  municipal  governments.  It  is  an 
especial  gratification  to  record  the  stimulating  recognition  of  these  rela- 
tionships by  the  social  and  economic  section  of  this  association  in  which 
was  started  a  year  and  a  half  ago  a  movement  for  public  health,  par- 
ticularly as  related  to  the  federal  government,  which  has  already  as- 
sumed national  significance. 

To  the  marvelous  growth  of  the  medical  and  other  sciences  of  living 
beings  during  the  past  century,  and  especially  in  the  last  fifty  years, 
physics  and  chemistry  and  the  application  of  physical  and  chemical 
methods  of  study  have  contributed  directly  and  indirectly  a  very  large 
and  ever-increasing  share.  In  many  instances  there  is  no  telling  when 
or  where  or  how  some  discovery  or  new  invention  may  prove  applicable 
to  medical  science  or  art.  Who  could  have  dreamed  in  1856  that  Sir 
William  Perkin's  production  of  the  first  aniline  dye  should  be  an 
essential  link  in  the  development  of  modern  bacteriology  and  therefore 


MEDICINE    AND    OTHER    SCIENCES    OF   NATURE  163 

in  the  crusade  against  tuberculosis  and  other  infectious  diseases?  As 
Eobert  Koch  has  said,  it  would  have  been  quite  impossible  for  him  to 
have  developed  his  methods  and  made  his  discoveries  without  the  posses- 
sion of  elective  dyes  for  staining  bacteria,  and  no  other  class  of  color- 
ing agents  has  been  discovered  which  can  serve  as  substitutes  for  the 
anilines  in  this  regard.  And  how  much  assistance  these  dyes  have 
rendered  to  the  study  of  the  structure  and  even  the  function  of  cells ! 
If  we  trace  to  their  source  the  discovery  of  Rontgen's  rays,  which  have 
found  their  chief  practical  application  in  medicine  and  surgery,  we  shall 
find  an  illustration  scarcely  less  striking. 

No  important  generalization  in  physical  science  is  without  its  influ- 
ence, often  most  important,  upon  biological  conceptions  and  knowledge. 
I  have  already  referred  to  the  great  principles  of  conservation  of  mass 
and  of  energy  which  are  at  the  very  foundation  of  our  understanding  of 
vital  phenomena.  Although  we  can  not  now  foresee  their  bearings, 
we  may  be  sure  that  the  new  theories,  regarding  the  constitution  of  what 
has  hitherto  been  called  matter,  will,  as  they  are  further  developed,  prove 
of  the  highest  significance  to  our  conceptions  of  the  organic  as  well  as  of 
the  inorganic  world.  Clerk  Maxwell  in  his  article  on  the  atom  in  the 
ninth  edition  of  the  Encyclopaedia  Britannica,  on  the  basis  of  a  com- 
putation of  the  number  of  molecules  in  the  smallest  organized  particle 
visible  under  the  microscope,  reached  a  conclusion  which  he  states  in 
these  words : 

Molecular  science  .  .  .  forbids  the  physiologist  from  imagining  that  struc- 
tural details  of  infinitely  small  dimensions  can  furnish  an  explanation  of  the 
infinite  variety  which  exists  in  the  properties  and  functions  of  the  most  minute 
organism. 

Larmor,  in  the  tenth  edition  of  the  same  work  in  his  article  on  the 
ether,  points  out  that  upon  the  assumption  of  either  vortex  atoms  or 
electric  atoms  physical  science  is  concerned  only  with  the  atmosphere  of 
the  atom,  that  is  with  the  modification  impressed  on  the  surrounding 
ether,  whereas  the  nucleus  or  core  of  the  atom  may  perhaps  be  taken 
into  account  in  the  problems  of  biology,  although  it  would  appear  that 
nothing  can  be  known  of  this  nucleus.  With  still  later  developments  of 
the  dynamJcal  hypothesis,  which  resolves  matter  into  nothing  but  activity 
or  energy,  there  are  those  who  think  that  the  hard  knot  of  ages  is  to 
be  untied  and  the  animate  and  inanimate  worlds  come  together  under  a 
satisfying  monistic  view  of  the  whole  as  in  essence  active  energy. 

The  ultimate  problems  of  biology  reside  in  the  cell.     Whatever  the 


164  MEDICAL   BESEABCH   AND   EDUCATION 

future  may  hold  in  store,  at  the  present  day  only  a  relatively  small 
part  of  these  problems  are  approachable  by  physical  or  chemical  methods, 
and  the  day  is  far  distant,  if  it  ever  comes,  when  cellular  physiology 
shall  be  nothing  but  applied  physics  and  chemistry.  We  can  not  foresee 
a  time  when  purely  observational  and  descriptive  biological  studies, 
which  to-day  hold  the  first  place,  shall  not  continue  to  have  their  value. 
They  represent  the  direction  which  makes  the  strongest  appeal  to  the 
great  majority  of  naturalists.  The  broadest  generalizations  hitherto 
attained  in  biology,  the  doctrine  of  the  cell  as  the  vital  unit  and  the 
theory  of  organic  evolution,  have  come  from  this  biological,  as  dis- 
tinguished from  physical,  direction  of  investigating  living  organisms, 
and  were  reached  by  men  with  the  type  of  mind  of  the  pure  naturalist, 
who  loves  the  study  of  forms,  colors,  habits,  adaptations,  inheritances 
of  living  beings. 

It  is  well  that  the  sciences  of  nature  hold  out  attractions  to  so  many 
different  types  of  mind,  for  the  edifice  of  science  is  built  of  material 
which  must  be  drawn  from  many  sources.  A  quarry  opened  in  the 
interest  of  one  enriches  all  of  these  sciences.  The  deeper  we  can  lay 
the  foundations  and  penetrate  into  the  nature  of  things,  the  closer  are 
the  workers  drawn  together,  the  clearer  becomes  their  community  of 
purpose,  and  the  more  significant  to  the  welfare  of  mankind  the  up- 
ibuilding  of  natural  knowledge. 


I 


MEDICINE    AND   THE   UNIYEESITY^ 

By  William  H.  AVelch,  M.D.,  LL.D., 

Professor  of  Pathology,  The  Johns  Hopkins  Universitt 

I  BELIEVE  that  I  make  no  mistake  in  assuming  that  the  honor  of 
the  invitation  to  deliver  this  address  came  to  me  mainly  through  the 
official  position  which  I  chance  to  hold  in  the  Association  for  the  Ad- 
vancement of  Science  and  the  desire  to  give  prominence  on  this  occasion 
to  the  sciences  of  nature  in  view  of  the  approaching  meeting  of  the 
association  in  this  place.  I  must,  however,  disclaim  any  especial  com- 
petence to  speak  for  these  sciences,  and  I  know  not  where  there  is  less 
need  in  our  country  of  emphasizing  the  importance  and  significance  of 
the  natural  and  physical  sciences,  or  where  the  representatives  of  these 
sciences  have  brought  higher  distinction  to  themselves  and  to  their  uni- 
versity, than  here  in  the  University  of  Chicago. 

The  past  century  is  memorable  above  all  others  for  the  gigantic 
progress  of  the  natural  and  physical  sciences — a  progress  which  has 
influenced  more  profoundly  the  lives  and  thought,  the  position  and 
prospects  of  mankind,  than  all  the  political  changes,  all  the  conquests, 
all  the  codes  and  legislation.  In  this  marvelous  scientific  advancement 
in  all  directions  the  sciences  of  living  beings  and  their  manifestations 
have  progressed  as  rapidly  and  have  influenced  the  material,  intellectual 
and  social  conditions  of  mankind  as  much  as  the  sciences  of  inanimate 
matter  and  its  energies.  So  far  as  the  happiness  of  human  beings  is 
concerned,  there  is  no  other  gift  of  science  comparable  to  the  increased 
power  acquired  by  medicine  to  annul  or  lessen  physical  suffering  and 
to  restrain  the  spread  of  pestilential  diseases,  although  what  has  been 
accomplished  in  this  direction  is  small  indeed  in  comparison  with  what 
remains  to  be  achieved.  Man's  power  over  disease  advances  with  in- 
creased knowledge  of  the  nature  and  causes  of  disease,  and  this  increase 
of  knowledge  has  its  sources  in  the  educational  system. 

In  asking  your  attention  on  this  occasion  to  some  of  the  conditions 
and  problems  of  medical  education  and  research,  particularly  in  their 

^  An  address  delivered  at  the  convocation  exercises  of  the  University  of 
Chicago,  December  17,  1907.     Published  in  Science,  January  3,  1908. 

165 


166  MEDICAL   BESEABCH   AND    EDUCATION 

relation  to  the  university  and  to  circumstances  existing  in  this  country, 
I  am  aware  that  the  theme  is  trite  and  that  I  can  add  little  that  is 
new  to  its  discussion,  but  the  subject,  however  wearisome,  requires  ever 
renewed  consideration  so  long  as  the  conditions  remain  as  unsatisfactory 
as  at  present  and  so  many  problems  await  final  solution.  Especially  is 
it  important  that  the  nature  of  the  problems  should  be  realized  by  the 
teachers  and  authorities  of  our  universities.  I  know  that  in  this  uni- 
versity much  earnest  thought  has  been  given  to  questions  of  medical 
education,  and  wisely  so,  for  I  have  every  confidence  that  the  medical 
department  of  this  university,  already  doing  such  good  work,  is  destined 
to  be  a  leader  in  the  promotion  of  higher  medical  education  and  the 
advancement  of  medical  knowledge  on  this  continent. 

The  historical  and  the  proper  home  of  the  medical  school  is  the 
university,  of  which  it  should  be  an  integral  part  coordinate  with  the 
other  faculties.  Before  there  was  a  faculty  of  law  at  Bologna  or  of 
theology  at  Paris  there  was  a  school  of  medicine  at  Salernum,  which, 
as  is  well  known,  occupies  an  interesting  and  unique  position  in  the 
history  of  the  origin  and  development  of  universities.  From  this  early 
period  to  the  present  day  no  other  type  of  medical  school  has  existed 
on  the  continent  of  Europe  than  that  of  the  university,  and  this  union 
has  been  of  mutual  advantage,  the  renown  of  many  universities  being 
due  in  large  part  to  their  medical  faculties,  and  these  receiving  the 
fostering  care  and  the  ideals  of  the  university. 

It  was  under  the  influence  of  these  sound  traditions  of  the  proper 
relation  of  medical  teaching  to  the  universities  that  the  first  medical 
schools  in  this  country  were  founded,  that  of  the  College  of  Philadelphia, 
now  the  University  of  Pennsylvania,  in  1765;  that  of  Kings  College, 
now  Columbia  University,  in  1767,  and  after  somewhat  longer  intervals 
those  of  Harvard,  Dartmouth  and  Yale.  The  model  for  these  early 
schools  was  the  medical  department  of  the  University  of  Edinburgh, 
which  derived  its  traditions  from  the  University  of  Leyden,  as  these  in 
turn  can  be  traced  back  to  the  great  Italian  universities  of  the  sixteenth 
century.  "We  can  contemplate  with  much  pride  and  satisfaction  the 
early  history  of  these  first  American  medical  schools,  which,  notwith- 
standing their  feeble  resources,  were  imbued  with  a  spirit  of  high 
purpose  and  just  recognition  of  the  qualifications  needed  for  the  pursuit 
of  medicine  as  a  learned  profession. 

It  is  deeply  to  be  regretted  that  their  successors  did  not  continue 


MEDICINE   AND    THE    UNIVERSITY  167 

to  build  on  such  foundations  as  those  laid  by  John  Morgan,  William 
Shippen  and  Samuel  Bard,  but  rather  adopted  and  carried  much  further 
the  plan  of  the  proprietary  medical  schools  which  originated  in  England 
in  the  latter  part  of  the  eighteenth  century  and  attained  their  highest 
development  there  during  the  first  three  decades  of  the  following  cen- 
tury, after  which  the  hospital  medical  schools  of  a  type  peculiar  to  that 
country  gained  the  ascendancy.  We  can  transfer  from  our  shoulders, 
however,  only  a  minor  part  of  the  responsibility  for  the  conception  and 
establishment  of  the  proprietary  medical  school,  for  the  English  form 
of  this  school  was  a  harmless  thing  which  never  dreamed  of  conferring 
the  doctor's  degree  and  was  regarded  with  disfavor  by  examining  and 
licensing  bodies. 

The  proprietary  medical  school,  conducted  for  gain,  divorced  from 
any  connection  with  a  university  and  free  from  any  responsible  outside 
control  whatever,  empowered  by  the  state  to  usurp  the  university's  right 
of  conferring  the  doctor's  degree  and  at  liberty  to  set  whatever  standards 
it  chose  for  obtaining  this  degree,  which  carried  with  it  the  license  to 
practise,  is  a  phenomenon  unique  in  the  history  of  education  and  a 
contribution  to  systems  of  education  for  which  America  is  entitled  to 
the  sole  credit.  This  is  the  type  of  medical  school  which  prevailed  in 
this  country  during  the  greater  part  of  the  nineteenth  century,  and 
familiarity  has  made  it  difficult  for  us  fully  to  realize  how  anomalous 
and  monstrous  it  really  is.  Even  in  the  case  of  those  schools  which 
were  united  with  a  college  or  university  the  connection  became  in  most 
instances  so  loosened  as  to  be  merely  nominal  and  to  secure  practical 
autonomy  to  the  medical  school.  In  the  common  type  of  these  schools 
there  was  no  requirement  of  preliminary  study  worthy  of  the  name,  the 
only  practical  training  was  in  the  dissecting  room  and  an  occasional 
amphitheater  clinic,  and  the  degree  and  license  to  practise  followed  the 
passing  of  an  easy  examination  after  attendance  on  two  annual  courses 
of  lectures  lasting  five  or  six  months  each,  sometimes  an  even  shorter 
period,  the  student  hearing  the  same  lectures  each  year. 

It  is  needless  to  say  that  such  conditions  brought  great  reproach  to 
American  medicine  and  introduced  evils  from  which  we  are  not  yet 
wholly  free.  Nevertheless,  the  system,  bad  as  it  was,  can  be  painted  in 
too  dark  colors.  The  rapid  multiplication  of  medical  schools  which  fol- 
lowed the  second  decade  of  the  last  century  was,  although  excessive,  in 
response  to  the  needs  of  a  rapidly  developing  country  pushing  the 


168  MEDICAL   BESEABCH   AND    EDUCATION 

boundaries  of  civilization  ever  westward.  Still  it  would  be  difficult  to 
find  a  sound  argument  for  increasing  the  hardships  of  frontier  settle- 
ments and  struggling  communities  by  a  supply  of  poor  doctors. 

The  main  relief  to  the  picture  is  that  the  results  were  not  so  bad 
as  the  system.  Many  of  the  teachers  were  devoted,  able  men  who 
imparted  sound  professional  traditions  and  whose  personality  in  a 
measure  remedied  the  defects  of  the  system.  The  native  force,  ability 
and  zeal  of  many  students  enabled  them  to  overcome  serious  obstacles 
and  to  acquire  in  the  course  of  time,  in  spite  of  adverse  circumstances, 
a  mastery  of  their  calling,  perhaps  a  resourcefulness  engendered  by 
these  circumstances,  for  even  under  the  best  conditions  education  does 
not  end  with  the  modicum  of  knowledge  imparted  in  school  and  college. 
Some  were  so  fortunate  as  to  be  able  to  supplement  their  inadequate 
training  by  European  study.  But  among  those  without  foreign  train- 
ing who  were  entirely  the  products  of  American  conditions  not  a  few 
were  the  peers  of  their  European  contemporaries,  such  as  Daniel  Drake, 
Jacob  Bigelow,  John  D.  Godman,  William  Beaumont,  Nathan  Smith 
Davis,  Samuel  D.  Gross,  Austin  Flint,  Marion  Sims  and  others  who 
have  left  names  illustrious  in  the  annals  of  our  profession.  Native 
vigor  and  resourcefulness  enabled  such  men  to  surmount  defects  of  an 
educational  environment  to  which  the  average  man  must  succumb. 

Most  gratifying  is  the  rapidity  with  which  medical  education  has 
risen  during  the  last  two  decades  from  the  low  estate  to  which  it  had 
sunk  during  the  greater  part  of  the  past  century  in  this  country. 
Among  the  more  important  causes  contributing  to  this  result  may  be 
mentioned  the  operation  of  laws  transferring  and,  in  fact,  restoring  the 
licensure  to  practise  from  the  medical  schools  to  state  boards  of  ex- 
aminers, whereby  worthless  medical  schools  are  crowded  to  the  wall  and 
out  of  existence  and  others  have  been  compelled  to  raise  their  standards, 
the  moral  pressure  exerted  through  an  awakened  sentiment  for  reform 
on  the  part  of  the  organized  profession  and  the  better  schools,  closer 
union  between  medical  school  and  university  and  the  consequent  interest 
of  university  teachers  and  authorities  in  the  problems  of  medical  educa- 
tion, the  example  set  by  a  few  schools  of  a  high  order,  endowment — 
although  very  inadequate — of  medical  education,  which  formerly  was 
almost  wholly  neglected  as  an  object  in  need  or  worthy  of  private  or 
public  beneficence,  the  advancement  of  medical  science  and  art,  neces- 
sitating improved  methods  and  higher  standards  of  professional  train- 


MEDICINE   AND    THE    UNIVEBSITY  169 

ing,  and  a  juster  and  wider  appreciation  of  the  significance  of  curative 
and  preventive  medicine  to  the  welfare  of  the  community. 

The  history  of  medical  education  in  America  is  still  in  the  making, 
but  we  now  have  a  number  of  schools  with  high  standards  and  adequate 
equipment  capable  of  giving  to  students  of  medicine  a  professional 
education  as  good  as  that  to  be  obtained  in  European  universities.  The 
best  and  most  progressive  schools  are  those  in  organic  union  with  a 
university,  and  it  seems  clear  that  to  schools  of  this  type  belongs  the 
future  of  higher  medical  education  in  this  country.  Nearly  twenty 
years  ago  in  an  address  at  Yale  University  I  endeavored  to  set  forth 
the  advantages  of  the  union  of  medical  school  and  university,  and,  as 
addresses,  fortunately  for  those  in  the  habit  of  giving  them,  are  soon 
forgotten,  I  shall  here  summarize  what  I  conceive  to  be  the  more  promi- 
nent of  these  advantages. 

Of  all  professional  and  technical  schools  the  medical,  with  its  re- 
quirements for  laboratories,  hospitals  and  teaching  force,  is  the  most 
costly.  A  medical  department  of  a  university  is  much  more  likely  to 
be  the  recipient  of  endowment  funds  than  an  independent  school,  and 
the  university  is  a  safer  and  more  suitable  custodian  of  such  funds. 

In  manifold  ways  the  environment  of  a  university  is  that  best  adapted 
to  the  teaching  and  the  advancement  of  medicine.  The  medical  school 
needs  the  ideals  of  the  university  in  maintaining  the  dignity  of  its 
high  calling,  in  laying  a  broad  foundation  for  professional  study,  in 
applying  correct  educational  principles  in  the  arrangement  of  the  cur- 
riculum and  in  methods  of  instruction,  in  assigning  the  proper  place  and 
share  to  the  scientific  and  the  practical  studies,  in  giving  due  emphasis 
to  both  the  teaching  and  the  investigating  sides  of  its  work,  in  stimu- 
lating productive  research,  and  in  determining  what  shall  be  the  quali- 
fications of  its  teachers  and  of  the  recipients  of  its  degree.  Most  in- 
vigorating is  the  contact  of  medical  teachers  and  investigators  with 
workers  in  those  sciences  on  which  medicine  is  dependent — chemistry, 
physics  and  biology. 

In  the  selection  of  teachers — a  matter  of  the  first  importance — a 
university  is  in  a  superior  position  to  secure  the  best  available  men 
wherever  they  can  be  found,  regardless  of  any  other  consideration  than 
fitness.  Too  often  this  choice  has  been  determined  in  our  medical 
schools  by  irrelevant  influences  and  considerations  and  an  outlook  upon 
the  world  scarcely  more  than  parochial  in  extent. 


170  MEDICAL   SESEABCH   AND    EDUCATION 

In  the  diflEicult  matter  of  adjustment  of  professional  training  to  con- 
ditions of  collegiate  education  peculiar  to  our  country  there  are  manifest 
advantages  in  the  union  of  medical  school  with  university,  especially 
where  the  periods  of  liberal  and  of  professional  study  are  made  to  over- 
lap. "Where  the  sciences  adjuvant  to  medicine,  as  general  chemistry, 
physics,  zoology  and  botany,  are  included  in  the  medical  curriculum,  as 
is  done  in  the  German  and  French  universities,  it  is  economical  and 
highly  desirable  that  they  should  be  taught  in  the  collegiate  or  philo- 
sophical faculty  rather  than  that  separate  provision  should  be  made  for 
them  in  the  medical  faculty,  where  they  do  not  properly  belong. 

The  benefits  of  union  of  medical  school  and  university  are  reciprocal, 
and  not  to  the  medical  school  alone.  A  good  medical  faculty,  properly 
supported  and  equipped,  is  a  source  of  strength  and  of  renown  to  the 
university  possessing  it,  and  its  work  in  training  students  and  in  ex- 
tending the  boundaries  of  knowledge  greatly  increases  the  usefulness 
of  the  university  to  the  community.  Nor  is  there  anything  in  this  work 
which  does  not  appertain  to  the  proper  functions  of  a  university,  how- 
ever high  its  ideals.  Indeed  I  venture  to  assert  that  the  present  and 
prospective  state  of  medicine  and  its  relations  to  the  well-being  of 
individual  man  and  of  human  society  are  such  that  there  is  no  higher 
or  nobler  function  of  a  university  than  the  teaching  of  the  nature  of 
disease  and  how  it  may  be  cured  and  prevented,  and  the  advancement 
of  the  knowledge  on  which  this  conquest  of  disease  depends.  If  it  be 
said  that  the  medical  art  is  largely  empiric,  I  reply  that  this,  while  true, 
does  not  make  medicine  unworthy  of  shelter  in  the  university.  The 
empiric  method  of  discovery  by  trial  and  error  has  its  glorious  triumphs 
as  well  as  the  scientific  and  is  not  to  be  disdained.  To  it  we  owe  such 
beneficial  discoveries  as  the  curative  properties  of  quinine  in  malaria, 
vaccination  against  smallpox  and  the  anesthetic  uses  of  ether  and 
chloroform. 

But  there  is  a  scientific  as  well  as  an  empiric  side  to  medicine  and 
the  distinctive  feature  of  modern  medicine  is  the  rapid  extension  of  the 
former  and  the  curtailment  of  the  latter.  The  fundamental  medical 
sciences — anatomy,  physiology,  physiological  chemistry,  pathology, 
pharmacology,  bacteriology  and  hygiene — are  rapidly  advancing  and  im- 
portant departments  of  biological  science,  which  have  contributed  and 
will  continue  to  contribute  enormously  to  the  progress  of  practical  medi- 
cine.    In  an  address  which  I  had  the  honor  to  deliver  somewhat  over 


MEDICINE   AND    THE    UNIFEESITY  171 

ten  years  ago  at  the  dedication  of  the  Hull  Biological  Laboratories  of 
this  university  I  took  occasion  to  dwell  with  some  detail  upon  the 
biological  aspects  of  medicine.    . 

"We  should  add  to  the  specialized  medical  sciences  already  mentioned 
the  study  of  the  problems  presented  by  the  living  patient  in  hospitals 
and  laboratories  attached  to  hospital  clinics  where  chemical,  physical 
and  biological  methods  can  be  applied  to  the  investigation  of  clinical 
problems,  which  do  not  fall  within  the  scope  of  other  laboratories  or 
can  be  less  advantageously  attacked  in  them.  These  clinical  investi- 
gating laboratories  are  an  important  addition  to  the  older  analytical  and 
statistical  methods  of  study  of  disease  and  mark  an  advance  from  which 
valuable  results  have  been  obtained  and  more  valuable  ones  are  to  be 
expected.  It  is  highly  desirable  that  our  medical  clinics  should  be 
organized  with  regard  to  this  newer  direction  of  work,  for  which  they 
will  require  considerable  funds. 

The  science  of  medicine  has  advanced  in  recent  years  more  rapidly 
than  the  art  and  in  its  various  branches  it  constitutes  to-day  a  field  of 
work  most  alluring  and  most  rewarding  to  the  properly  trained  scien- 
tific investigator,  who,  if  he  have  the  rare  genius  for  discovery,  may 
reap  a  harvest  rich  in  blessing  to  mankind. 

But  the  art  of  medicine  has  profited  greatly  by  the  application  of 
scientific  discoveries.  The  physician  and  the  surgeon  to-day  can  do  far 
more  in  the  relief  of  physical  suffering  and  in  the  successful  treatment 
of  disease  and  injury  than  was  formerly  possible,  but  the  great  triumphs 
have  been  in  the  field  of  preventive  medicine.  The  horizon  of  the 
average  man's  interest' in  medicine  scarcely  extends  beyond  the  circum- 
ference of  his  own  body  or  that  of  his  family,  and  he  measures  the 
value  of  the  medical  art  by  its  capacity  to  cure  his  cold,  his  rheumatism, 
his  dyspepsia,  his  neurasthenia,  all  unconscious,  because  he  does  not 
encounter  them,  of  the  many  perils  which  medicine  has  removed  from 
his  path  through  life.  What  does  he  know  of  the  decline  in  the  death 
rate  by  one  half  and  of  the  increase  in  the  expectation  of  life  by  ten 
or  twelve  years  during  the  last  century?  How  many  are  there  whose 
attention  has  been  called  to  the  significant  fact  that  this  increase  in  the 
expectation  of  life  ceases  with  the  forty-fifth  year  because  we  have  as 
yet  no  such  insight  into  the  causes  and  prevention  of  the  organic  diseases 
of  advancing  life  as  we  have  into  the  manner  of  propagation  of  infec- 
tious diseases,  which  are  responsible  for  the  larger  part  of  the  mortality 


172  MEDICAL   BESEAECE   AND    EDUCATION 

of  the  earlier  years?  The  suffering  and  the  waste  of  energy,  money, 
production  and  human  lives  from  preventable  sickness  and  death  are 
gtill  incalculable,  but  how  little  heed  do  legislators  and  authorities  in 
our  national,  state  and  municipal  governments  pay  to  the  appeals  of 
physicians  and  enlightened  economists  to  make  adequate  provision  to 
check  this  waste !  For  this  condition  of  things  the  medical  profession 
is  largely  responsible  in  failing  to  enlighten  the  public  and  in  shrouding 
its  art  with  the  mystery  of  an  occult  science,  but  it  is  beginning  to  rise 
to  its  high  mission  of  public  education  in  ways  of  preserving  health  and 
of  preventing  disease. 

I  have  touched  on  these  matters  relating  to  the  present  and  future 
state  of  the  science  and  art  of  medicine,  not  with  the  view  of  recounting 
the  achievements  of  modern  medicine,  but  to  indicate  something  of  their 
importance  to  individual  and  to  civic  life  and  to  show  that  in  fostering 
the  teaching  and  study  of  medicine  the  university  finds  a  field  worthy  of 
its  highest  endeavors  in  the  propagation  of  useful  knowledge  and  in 
service  to  the  community. 

From  what  has  been  said  we  may,  I  think,  assume  with  confidence 
that  the  best  and  in  time  the  prevailing  type  of  American  medical 
school  is  destined  to  be  that  represented  in  medical  departments  in 
vital  union  with  universities.  In  so  far  our  system  of  medical  education 
will  conform  to  that  of  Germany  and  France,  but  in  an  important 
respect  there  is  and  will  doubtless  remain  a  difference  due  to  the  fact 
that  in  those  countries  the  courses  of  study  and  the  qualifications  for 
the  degree  and  the  license  to  practise  are  molded  into  practical  uni- 
formity by  the  regulations  of  the  state.  Nothing  is  more  characteristic 
of  the  conditions  of  medical  education  in  our  country  than  the  great 
diversity  of  the  requirements  and  curricula  of  the  various  medical 
schools,  even  of  those  of  the  better  sort.  Entire  uniformity  is  not  to 
be  expected  and  not  to  be  desired,  but  at  least  such  a  measure  of  agree- 
ment should  be  secured  as  will  permit  students  to  pass  freely  from  one 
university  to  another  and  to  acquire,  it  is  to  be  hoped,  something  of  the 
habit  of  wandering  which  is  such  an  enviable  feature  of  student  life  in 
the  German  universities. 

No  problem  of  medical  education  in  this  country  is  so  perplexing  or 
has  given  rise  in  recent  years  to  so  much  discussion  and  difference  of 
opinion  as  that  of  the  preliminary  education  to  be  required  for  the  study 
of  medicine.     If  I  could  announce  a  universally  satisfactory  solution 


MEDICINE   AND    TEE    UNIFEBSITY  173 

of  this  problem,  I  should  claim  the  honors  of  an  important  discovery, 
but  as  I  can  not  do  so  I  shall  forego  on  this  occasion  its  detailed  dis- 
cussion, with  a  self-sacrificing  forbearance  which  I  trust  may  be  com- 
mended by  my  hearers.  It  must  suflEice  to  enumerate  the  attempts  at 
a  solution,  premising,  what  is  generally  recognized,  that  the  difficulties 
arise  from  the  anomalous  development  of  the  American  college  for  many 
years,  making  it,  however  admirable  it  may  be  for  certain  educational 
uses,  almost  unadjustable  to  the  needs  of  professional  education. 

The  preliminary  requirement  of  the  bachelor's  degree  in  arts  or 
science  should,  in  my  judgment,  carry  with  it  the  specification  of  col- 
legiate laboratory  training  in  physics,  chemistry  and  biology,  with  a 
reading  knowledge  of  French  and  German.  These  requirements  have 
been  in  successful  operation  in  the  medical  department  of  the  Johns 
Hopkins  University  since  its  foundation  in  1893,  their  adoption  being 
necessitated  by  the  acceptance  of  the  terms  of  Miss  Garrett's  gift- of 
endowment.  We  are  satisfied  with  the  working  of  these  requirements 
and  would  not  lower  them  if  we  could,  but  it  must  be  conceded  that, 
while  there  is  room  for  medical  schools  with  these  standards,  the  country 
is  not  ripe  for  their  general  adoption.  The  medical  department  of 
Cornell  University  has  recently  announced  the  intention  to  introduce 
similar  requirements,  and  the  Harvard  University  Medical  School 
demands  the  bachelor's  degree  without  the  other  requirements  men- 
tioned. 

In  order  to  meet  the  objection  that  the  average  age  of  graduation 
from  OUT  colleges  is  at  least  two  years  beyond  that  at  which  professional 
study  usually  begins  in  Europe,  various  attempts  have  been  made  to 
truncate  the  college  course  or  to  telescope  a  quarter  to  a  half  of  it  into 
the  period  of  professional  study,  making  one  course  of  study  count  for 
two  degrees.  Manifest  objections  and  embarrassments  attend  all  of 
these  attempts  to  find  a  suitable  stopping  place  between  the  high  school 
and  the  end  of  the  college  course.  The  plan  adopted  in  this  university 
to  demarcate  with  some  sharpness  the  first  two  years  of  the  college 
course  from  the  remainder  and  to  exact  the  completion  of  these  two 
years  of  study  as  the  requirement  preliminary  to  the  study  of  medicine 
has  much  to  recommend  it  under  existing  conditions.  I  learn  from  the 
last  report  of  the  Council  on  Medical  Education  of  the  American 
Medical  Association  that  one  medical  school,  the  medical  department  of 
Western  Reserve  University,  demands  as  a  prerequisite  to  the  study  of 


174  MEDICAL   EESEABCH   AND   EDUCATION 

medicine  three  years  of  study  in  a  college  of  arts  or  science,  sixteen 
require  two  years  of  collegiate  study,  eleven  of  these  schools  being  in  the 
middle  west  or  west,  and  thirty-one  require  one  year,  of  these,  nineteen 
being  in  the  middle  west  or  west. 

The  Council  on  Medical  Education  just  mentioned,  of  which  Dr. 
Bevan  is  the  energetic  and  eflScient  chairman,  has  entered  as  a  strong 
force  for  the  elevation  of  standards  of  medical  education  in  this  country, 
and,  while  it  has  not  the  power  of  the  British  General  Medical  Council 
to  make  effective  its  recommendations,  it  can  exert  a  most  beneficial 
influence.  It  is  significant  that  at  its  first  conference,  held  in  1905,  it 
recommended  as  the  minimum  preliminary  requirement  to  be  generally 
adopted  by  our  medical  schools  an  education  sufficient  to  enable  the 
student  to  enter  the  freshman  class  of  a  recognized  college  of  arts  or  a 
university,  and  now  it  recommends  that  in  1910  to  this  shall  be  added 
a  year's  study  of  physics,  chemistry  and  biology,  with  one  modern 
language,  preferably  German.  The  time  has  gone  by  when  it  is  neces- 
sary to  emphasize  before  an  audience  such  as  this  the  importance  of 
laboratory  training  in  physics,  chemistry  and  general  biology  as  funda- 
mental to  the  successful}  study  of  medicine. 

While  it  is  not  feasible  to  exact  the  preliminary  study  of  the  ancient 
classics,  save  some  acquaintance  with  Latin,  I  feel  that  they  are  of  value 
to  the  physician  and  that  a  liberal  education  and  broad  culture  raise  the 
influence  and  standing  of  the  physician  in  the  community,  enhance  and 
widen  the  intellectual  pleasures  of  his  life,  instil  an  interest  in  the 
history  of  medicine  and  give  him  greater  joy  in  the  pursuit  of  a  noble 
profession.  It  is  important,  especially  for  medicine,  that  this  culture 
be  imparted  by  methods  of  liberal  education  which  do  not  blunt  man's 
innate  curiosity  for  the  facts  of  nature. 

There  can  be  no  more  striking  evidence  of  the  progress  of  medical 
education  in  this  country  during  the  last  quarter  of  a  century  than  that 
it  is  no  longer  the  laboratory,  but  the  clinical  side  of  medical  teaching 
which  offers  the  urgent  problems.  Only  a  few  years  ago  the  cry  was 
the  need  of  laboratories;  now,  while  a  sufficient  supply  of  good  labora- 
tories is  still  beyond  the  resources  of  many  medical  schools,  their  value 
is  fully  recognized  and  all  of  our  better  schools  possess  them  and  are 
devoting  probably  as  much  of  the  time  and  energies  of  teachers  and 
students  to  work  in  the  laboratories  as  is  desirable.  There  is  even 
some  risk,  I  believe,  that  a  subject  which  can  be  studied  with  facility 


MEDICINE    AND    THE    UNIFEBSITT  175 

and  advantage  in  a  laboratory  may  acquire,  on  this  account,  a  position 
in  the  scheme  of  medical  studies  disproportionate  to  its  relative  im- 
portance. The  structure  of  organized  beings,  normal  or  diseased,  for 
example,  is  eminently  adapted  to  laboratory  study,  and  for  centuries 
normal  anatomy  had  an  educational  value  all  its  own,  because  it  was 
the  only  subject  which  students  were  taught  in  the  laboratory,  whereas 
the  study  of  function,  certainly  not  less  important,  is  much  more  difficult 
to  approach  by  the  laboratory  method,  and  even  at  the  present  time 
normal  physiology  and  especially  pathological  physiology  do  not  receive 
the  attention  in  medical  education  to  which  their  importance  entitles 
them. 

It  is  interesting  to  note  the  impressions  which  Professor  Orth,  of 
Berlin,  an  acute  observer  and  most  competent  judge  in  all  matters  per- 
taining to  medical  education,  received  from  his  visit  to  this  country 
three  years  ago  regarding  our  laboratories  and  clinics.  In  an  address 
conveying  these  impressions  to  the  Berlin  Medical  Society  he  expresses 
his  astonishment  and  satisfaction  that,  in  contrast  to  the  prevalent 
opinion  in  Germany  as  to  our  medical  schools,  he  found  that  fully  as 
much  emphasis  is  placed  on  laboratory  teaching  here  as  there,  that  the 
laboratories  which  he  visited  are  as  good,  their  arrangements  in  some 
instances  arousing  his  envy,  and  the  methods  of  teaching  practically  the 
same  as  in  German}'',  whereas  he  gathered  the  impression  that  the 
opportunities  and  methods  of  clinical  teaching  are  less  satisfactory  than 
in  Germany  and  not  commensurate  with  those  of  our  laboratories. 

I  do  not  desire  to  instil  sentiments  of  undue  complacency  regard- 
ing the  condition  of  laboratory  teaching  in  our  medical  schools,  for  there 
is  still  room  for  much  improvement  in  this  regard.  Many  schools  are 
sadly  deficient  and  even  the  best  have  not  all  that  is  needed  in  the 
supply  and  maintenance  of  laboratories,  but  the  time  has  come  to  give 
especial  emphasis  to  directions  of  improvement  in  the  teaching  of  prac- 
tical medicine  and  surgery.  The  making  of  good  practitioners  should 
always  be  kept  to  the  front  as  the  prime  purpose  of  a  medical  school. 

I  believe  that  in  most  medical  schools  at  present  the  clinic  falls 
behind  the  laboratory  in  affording  students  opportunities  for  that  pro- 
longed, intimate,  personal  contact  with  the  object  of  study,  in  this  in- 
stance the  living  patient,  which  is  essential  for  a  really  vital  knowledge 
of  a  subject.  To  secure  this,  amphitheater  clinics  and  ward  classes 
alone  do  not  suffice,  valuable  as  these  are,  but  students  under  suitable 


176  MEDICAL   BESEABCH   AND    EDUCATION 

restrictions  and  supervision  and  at  the  proper  period  in  their  course  of 
study  should  work  in  the  dispensary  and  should  have  free  access  to 
patients  in  the  public  wards  of  hospitals,  acting  in  the  capacity  of 
clinical  clerks  and  surgical  dressers  as  a  part  of  the  regular,  orderly 
machinery  of  the  hospital. 

In  order  to  place  the  clinical  side  of  medical  instruction  on  the  same 
satisfactory  foundation  as  that  of  laboratory  teaching,  two  reforms  are 
especially  needed  in  most  of  our  medical  schools. 

The  first  is  that  the  heads  of  the  principal  clinical  departments, 
particularly  the  medical  and  the  surgical,  should  devote  their  main 
energies  and  time  to  their  hospital  work  and  to  teaching  and  investiga- 
ting without  the  necessity  of  seeking  their  livelihood  in  a  busy  outside 
practise  and  without  allowing  such  practise  to  become  their  chief  pro- 
fessional occupation.  This  direction  of  reform  has  been  forcibly  urged 
in  this  city  and  elsewhere  by  my  colleague,  Dr.  Barker,  whom  we  have 
reclaimed  from  you,  in  notable  papers  and  addresses. 

The  other  reform  is  the  introduction  of  the  system  of  practical 
training  of  students  in  the  hospital,  which  I  have  indicated,  and  with  it 
the  foundation  and  support  of  teaching  and  investigating  laboratories 
connected  with  the  clinics,  to  which  I '  have  already  referred,  neces- 
sitating the  possession  of  a  hospital  by  the  medical  school  or  the  estab- 
lishment of  such  relations  with  outside  hospitals  as  will  make  possible 
these  conditions.  This  subject,  as  thus  outlined,  I  made  the  theme 
of  an  address  at  the  opening,  six  months  ago,  of  the  new  Jefferson 
Medical  College  Hospital  in  Philadelphia,  and  I  shall  now  recur  only  to 
the  point  which  I  endeavored  there  to  establish,  that  the  teaching 
hospital  subserves  the  interest  of  the  patient  not  less  than  that  of  the 
student  and  teacher  and  is  the  best  and  most  useful  kind  of  public 
hospital. 

Hospitals  make  generally  a  stronger  appeal  to  public  and  private 
philanthropy  than  the  support  of  medical  education,  but  I  do  not 
hesitate  to  affirm  that  a  general  hospital  in  a  university  city,  whether 
maintained  by  public  funds  or  by  private  benevolence,  serves  the  com- 
munity and  the  interests  of  its  patients  far  better  when  it  is  readily  ac- 
cessible and  freely  available  for  the  purposes  of  medical  education  than 
when  it  is  divorced  from  connection  with  medical  teaching.  Witness 
the  great  public  hospitals  in  Vienna,  Berlin,  Munich,  Leipsic,  Paris, 
London,  Edinburgh,  Dublin  and  a  few  in  this  country.     It  is  most 


MEDICINE   AND    THE    UNIVEESITY  177 

deplorable  both  for  the  hospitals  and  for  the  medical  schools  that  these 
two  institutions,  which  should  be  linked  arms  of  medical  education, 
should  have  developed  in  this  country  so  far  apart,  that  state  and 
municipal  authorities  and  private  founders  should  have  so  little  realiza- 
tion of  the  inestimable  advantages  which  close  association  with  a  good 
medical  school  can  confer  on  a  hospital,  and  that  the  immense  possi- 
bilities of  public  hospitals  in  our  large  cities  for  the  education  of 
students  and  physicians  and  for  the  advancement  of  medical  knowledge 
should  be  utilized  to  so  small  an  extent,  often  not  at  all. 

It  would  be  one  of  the  greatest  benefits  to  the  cause  of  higher  medical 
education  if  the  University  of  Chicago,  for  its  medical  department, 
should  come  into  possession  of  a  good  general  hospital  and  fortunate 
the  hospital  which  enters  into  this  relationship.  This  university,  the 
source  of  so  many  important  contributions  to  the  advancement  of 
knowledge  and  of  higher  education,  will  then  be,  in  larger  measure  than 
it  now  finds  possible,  a  center  of  similar  service  to  medicine. 

Medical  education  partakes  fully  of  the  freedom,  so  amazing  often  to 
many  of  our  European  colleagues,  with  which  we  unhesitatingly  try 
all  sorts  of  educational  experiments  in  this  country — it  is  to  be  hoped 
and  expected  for  the  ultimate  benefit  of  systems  of  education,  what- 
ever the  immediate  results  may  be  in  individual  cases.  The  theme  of 
this  address  naturally  suggests  many  topics  relating  to  methods  of  teach- 
ing and  to  the  medical  curriculum  which  are  questions  of  the  day,  but 
which  I  must  lay  aside  through  lack  of  time.  On  one  only  I  beg  to 
say  a  few  words. 

In  contrast  to  the  German  system,  the  tendency  in  our  American 
medical  schools  has  been  toward  a  rigid  curriculum,  which,  though 
widely  divergent  in  different  schools,  is  to  be  followed  in  precisely  the 
same  way  by  all  students  without  any  consideration  of  differing  ability, 
capacity  for  work,  special  aptitudes  and  interests.  One  of  many  un- 
fortunate results  is  that  subjects  and  courses  of  study  which  can  not 
properly  be  imposed  as  obligatory  on  already  overburdened  students 
find  no  place  in  our  medical  schools,  which  should  aim  to  cultivate 
the  whole  field  of  medicine.  I  agree  with  Dr.  Bowditch  and  my  col- 
league. Dr.  Mall,  to  whose  admirable  presentation  of  this  subject  I 
would  refer  those  interested,  that  our  students  should  have  a  greater 
latitude  of  choice  than  is  now  customary  in  subjects  to  be  pursued,  in 
the  amount  of  time  to  be  devoted  to  their  study  and  in  the  order  in 
13 


178  MEDICAL   BESEAECH   AND   EDUCATION 

which  they  may  be  taken.  Complete  freedom  can  not  be  granted.  A 
minimum  requirement  for  the  principal  subjects  must  be  made  obliga- 
tory, but  if  this  minimum  is  properly  fixed  there  remains  room  for  a 
considerable  range  of  choice  of  subjects  and  courses,  greatly  to  the 
advantage  of  student  and  teacher.  At  the  Harvard  Medical  School  the 
system  of  electives  for  the  fourth  year  of  the  course  has  been  in  opera- 
tion for  several  years,  and  other  medical  schools  have  also  introduced 
a  similar  plan.  At  the  beginning  of  the  current  academic  year  we 
adopted  at  the  Johns  Hopkins  Medical  School  a  scheme  by  which  a 
large  number  of  elective  courses  are  offered  throughout  the  four  years, 
and  the  plan  is  now  working  most  successfully. 

Some  of  our  state  boards  of  examiners  are  greatly  exercised  over  the 
differences  which  they  find  in  the  curricula  of  the  various  medical 
schools  in  this  country,  and  which  in  themselves  are  merely  an  indica- 
tion that  there  is,  and,  in  my  judgment,  there  can  be  no  agreement  of 
opinion  as  to  every  detail  of  a  medical  curriculum.  There  are  doubtless 
defects  to  be  remedied,  but  in  attempting  to  apply  remedies  these  state 
boards  should  concern  themselves  with  no  other  question  than  that  of 
educational  standards.  They  could  make  no  greater  mistake  nor  inflict 
more  serious  injury  on  the  efforts  of  the  better  schools  to  improve  their 
methods  of  teaching  than  to  attempt  to  impose  a  uniform  and  rigid 
obligatory  curriculum  on  all  schools.  They  do  not  in  their  examinations 
apply  any  practical  tests  whatever  to  determine  the  candidate's  fitness 
for  the  practise  of  medicine,  whereas  our  better  schools  are  exerting 
every  effort  to  increase  their  efficiency  by  substituting  practical  work  in 
laboratories,  hospital  wards  and  out-patient  departments  for  didactic 
lectures.  The  work  of  students  who  gain  their  knowledge  by  serving  as 
clinical  clerks  and  surgical  dressers  in  the  hospital  can  not  be  measured 
by  time  standards  in  the  same  precise  way  as  that  of  attendance  on 
expository  lectures.  Above  all,  the  better  schools  should  not  be 
hampered  by  restrictions  imposed  by  state  boards  of  examiners  in  free- 
dom to  extend  the  system  of  electives  of  which  I  have  spoken. 

The  medical  department  of  a  university  should  be  a  school  of 
thought,  as  well  as  a  school  of  teaching,  academia  as  well  as  schola. 
Although  there  has  been  gratifying  progress  in  recent  years,  our  medical 
schools  have  not  advanced  along  the  path  of  productive  research  to  the 
same  extent  that  they  have  in  the  way  of  improvement  of  their  educa- 
tional work.     There  are  several  reasons  for  this  condition.     For  one 


MEDICINE   AND    TEE    UNIVEBSITY  179 

thing  we  have  been  too  busy  setting  our  houses  in  order  for  their 
primary  uses  in  the  training  of  students  to  have  given  the  requisite 
attention  to  other  questions  which,  however  important,  may  have  seemed 
for  the  moment  less  urgent.  With  the  degree  of  emphasis  thus  placed 
on  the  educational  side  teaching  gifts  rather  than  investigating  capacity 
have  been  sought  as  the  most  desirable  qualification  of  professors  in  our 
medical  schools.  The  power  of  imparting  knowledge,  gained  second- 
hand, fluently  and  even  skilfully,  is  not  an  uncommon  gift  and  is 
possessed  by  many  who  have  never  engaged  in  research  and  have  no 
especial  inclination  or  aptitude  for  it,  but  the  teaching  of  him  who  has 
questioned  Nature  and  received  her  answers  has  often,  and  I  think 
commonly,  in  spite  it  may  be  of  defects  of  delivery,  a  rarer  and  more 
inspiring  quality. 

A  medical  school  or  university  can  not  expect  to  fill  all  of  its  chairs 
with  men  with  the  genius  for  discovery — if  it  has  one  or  two  it  has  a 
treasure  beyond  all  price — but  every  effort  should  be  made  to  secure  as 
occupants  of  these  chairs  from  among  those  who  are  available,  wherever 
they  can  be  found,  the  ones  who  have  demonstrated  the  greatest  capacity 
to  advance  knowledge  by  original  investigation  and  the  ability  to  stimu- 
late research.  Until  this  principle  is  more  fully  and  generally  recog- 
nized and  acted  on  in  the  selection  of  heads  of  departments,  our  medical 
schools  as  a  class  will  not  become  important  contributors  to  knowledge. 
It  is  not  enough  that  a  few  schools  should  encourage  and  provide  for 
original  investigation ;  the  field  must  be  a  wide  one  in  order  to  attract 
many  to  a  scientific  career,  for  of  the  many  only  a  few  will  be  found 
endowed  with  the  power  of  discovery.  There  is  no  possible  way  of 
recognizing  the  possessor  of  this  power  before  he  has  demonstrated  it. 
Even  when  a  university  has  succeeded  in  attaching  to  it  those  who  can 
conduct  scientific  inquiry  successfully,  how  often  are  their  energies 
sapped  by  lack  of  adequate  resources  and  enough  trained  assistants  and 
by  too  great  burden  of  teaching  and  administrative  work  imposed  on 
them! 

It  is  evident  from  what  has  been  said,  and  indeed  it  has  been  a 
tacit  assumption  throughout  this  address,  that,  while  with  present  re- 
sources considerable  improvement  in  medical  education  in  this  country 
is  possible,  further  progress  is  largely  a  question  of  ways  and  means. 
"What  makes  modern  medical  education  so  costly  is  precisely  its  practical 
character,  necessitating  laboratories  and  hospitals,  and  it  can  be  made 


180  MEDICAL   BESEABCH   AND    EDUCATION 

self-supporting  no  more  than  any  other  department  of  higher  education. 
For  reasons  already  stated,  the  medical  departments  of  strong  universi- 
ties are  the  ones  most  likely  to  receive  the  funds  needed  for  the  support 
of  medical  education  and  are  in  general  the  most  deserving.  There  is 
a  great  future  before  the  medical  schools  of  many  of  our  state  universi- 
ties, which  are  already  developing  with  such  promise  and  are  sure  to 
receive  in  increasing  measure  aid  from  the  state  as  their  needs  and  the 
benefits  accruing  to  the  community  from  their  generous  support  are 
more  and  more  fully  appreciated.  Other  universities  must  look  to 
private  endowment,  and  I  have  endeavored  to  show  that  they  should 
foster  their  departments  of  medicine  as  zealously  as  their  other  faculties. 
The  university  chest  should  be  opened,  so  far  as  possible,  to  supply  needs 
of  the  medical  school,  and  authorities  of  the  university  should  present 
the  claims  of  medical  education  to  financial  aid  as  among  the  most 
important  in  their  domain,  and  they  can  do  so  to-day  with  a  force  of 
appeal  not  possible  a  quarter  of  a  century  ago.  President  Eliot,  whose 
services  to  the  cause  of  medical  education  are  great,  in  his  address  at  the 
opening  of  the  new  buildings  of  the  Harvard  University  Medical  School, 
set  forth  with  admirable  force  and  clearness  the  changes  which  advanc- 
ing medicine  has  brought  in  the  vocation  of  the  physician,  his  greatly 
increased  capacity  of  service  to  the  community'  and  his  still  higher 
mission  in  the  future. 

The  discoveries  which  have  transformed  the  face  of  modern  medi- 
cine have  been  in  the  field  of  infectious  diseases,  and  in  no  other  depart- 
ment of  medicine  could  new  knowledge  have  meant  so  much  to  man- 
kind, for  the  infectious  diseases  have  a  significance  to  the  race  possessed 
by  no  other  class  of  disease  and  problems  relating  to  their  restraint  are 
scarcely  less  social  and  economic  than  medical.  The  public  is  awaken- 
ing to  this  aspect  in  the  case  of  tuberculosis,  and  I  need  only  cite  as  a 
further  example  the  necessity  of  keeping  in  check  the  malarial  diseases 
and  yellow  fever  for  success  in  digging  the  Isthmian  Canal,  an  under- 
taking in  which  the  triumphs  of  the  sanitarian.  Colonel  Gorgas,  are  not 
outrivaled  by  those  of  the  engineer.  Such  victories  over  disease  as  those 
of  the  prevention  of  hydrophobia  by  the  inoculation  of  Pasteur's  vaccine 
and  the  antitoxic  treatment  of  diphtheria  have  made  an  especially 
strong  impression  on  the  public  mind. 

More  than  all  that  had  gone  before  in  the  history  of  medicine  the 
results  achieved  during  the  last  quarter  of  a  century  in  exploration  of 


MEDICINE   AND    THE    UNIVEESITY  181 

the  fields  of  infection  and  immunity  opened  by  the  discoveries  of  Pasteur 
and  of  Koch  have  stirred  men's  minds  to  the  importance  of  advance- 
ment of  medical  knowledge,  and  medical  science  at  last  has  entered  into 
its  long  awaited  heritage  as  a  worthy  and  rewarding  object  of  public 
and  private  endowment.  But  it  is  to  be  noted  that  it  is  not  so  much 
the  education  of  doctors  as  this  advancement  of  knowledge  which  makes 
the  strong  appeal,  as  may  be  illustrated  by  the  splendid  foundation  of 
the  Rockefeller  Institute  for  Medical  Research  through  the  enlightened 
generosity  of  the  founder  of  this  university,  the  Phipps  Institute  for  the 
Study  and  Prevention  of  Tuberculosis,  and  the  Memorial  Institute  for 
the  Study  of  Infectious  Diseases,  established  in  this  city  by  Mr.  and 
Mrs.  Harold  McCormick,  which  under  the  efficient  direction  of  Dr. 
Hektoen  has  become  a  most  active  and  important  contributor  to  our 
knowledge  of  infection  and  immunity. 

These  magnificent  additions  to  the  resources  of  this  country  for  the 
promotion  of  medical  investigations  are  of  inestimable  value,  but  not 
one  of  them  could  have  justified  its  existence  by  results  if  it  had  been 
established  in  America  thirty  years  ago,  when  medical  education  was  so 
defective.  The  dependence  of  research  on  education  is  of  fundamental 
importance.  The  prime  factor  influencing  the  development  of  scien- 
tific research  in  any  country  is  the  condition  of  its  higher  education. 
Scientific  investigation  is  the  fruit  of  a  tree  which  has  its  roots  in  the 
educational  system,  and  if  the  roots  are  neglected  and  unhealthy  there 
will  be  no  fruit.  Trained  investigators  are  bred  in  educational  institu- 
tions. Independent  laboratories  are  dependent  on  a  supply  from  this 
source,  and  without  it  they  can  not  justify  their  existence,  but  where 
proper  standards  of  education  exist  such  laboratories  have  a  distinctive 
and  important  field  of  usefulness.  I  contend,  therefore,  that  those 
interested  in  the  advancement  of  medical  knowledge  should  not  be 
indifferent  to  the  condition  of  education  in  our  better  medical  schools 
and  should  not  rest  on  the  assumption  that  the  educational  side  can  be 
safely  left  to  take  care  of  itself. 

Moreover,  those  who  are  to  apply  the  new  knowledge  are  physicians 
and  sanitarians.  The  public  is  vitally  interested  in  the  supply  of  good 
physicians,  never  so  much  as  to-day  when  their  power  to  serve  the 
welfare  of  the  community  has  been  so  vastly  increased  and  is  rapidly 
growing,  and  if  it  wants  good  doctors  it  must  help  to  make  them. 

I  have  been  able,  within  the  limits  of  this  address,  to  indicate  only  a 


182  MEDICAL   BESEABCH   AND    EDUCATION 

relatively  small  part  of  the  increased  strength  gained  by  both  medical 
school  and  university  by  the  combination  of  their  forces,  but  I  hope  that 
I  may  have  conveyed  some  impression  of  the  rich  fields  of  discovery, 
of  the  beneficent  service  to  the  community,  of  the  important  educational 
work  opened  to  the  university  by  close  union  with  a  strong  department 
of  medicine,  and  of  the  inestimable  value  to  medicine  of  intimate  contact 
with  the  fructifying  influences  and  vitalizing  ideals  of  the  university. 
Where  is  there  a  university  which,  if  provided  with  the  requisite  re- 
sources, gives  stronger  assurance  of  securing  these  mutual  benefits  than, 
the  University  of  Chicago,  so  fruitful  in  achievement  during  its  brief 
but  eventful  history,  so  vigorous  in  its  present  life,  so  full  of  high 
promise  for  the  future,  and  where  in  all  this  land  is  there  a  location 
more  favorable  to  the  development  of  a  great  university  medical  school 
than  here  in  the  city  of  Chicago?  Such  a  development  is  bound  to 
come  and  the  sooner  it  arrives  the  earlier  the  day  when  America  shall 
assume  that  leading  position  in  the  world  of  medical  science  and  art 
assured  to  her  by  her  resources,  the  intelligence  of  her  people,  her  rank 
among  the  nations  and  her  high  destiny. 


THE    EELATIOX    OF   THE    HOSPITAL    TO    MEDICAL      , 
EDUCATION  AND  EESEARCm 

By  William  H.  Welch,  M.D.,  LL.D., 

Pkofessor  of  Pathology,  The  Johns  Hopkins  XJniveesity 

The  most  urgent  need  of  the  medical  schools  of  this  country  at 
the  present  time  is  the  possession  of  well-organized  and  well-equipped 
hospitals,  available  for  teaching,  and  I  esteem  it  a  great  privilege  to 
bring  greetings  and  congratulations  to  the  Jefferson  Medical  College 
on  this  splendid  addition  to  its  educational  resources.  Coming,  as  so 
many  of  us  do,  directly  from  the  meeting  of  the  American  Medical 
Association  in  Atlantic  City,  my  colleagues,  representing  the  medical 
profession  of  this  country,  will  surely  be  glad  to  have  me  express  on 
this  happy  occasion  in  their  behalf  congratulations  to  this  college  and  to 
this  city.  We  must  all  rejoice  in  the  enlarged  opportunities  for  bedside 
teaching  supplied  by  this  fine  hospital  to  the  Jefferson  Medical  College, 
which  from  its  foundation  over  eighty  years  ago  has  laid  especial 
emphasis  on  clinical  instruction,  which  has  sent  forth  so  many  graduates 
who  have  achieved  professional  success  and  eminence,  and  which  has 
possessed  such  distinguished  teachers  and  ornaments  of  our  profession 
as  McClellan,  Eberle,  Dunglison,  Bache,  Drake,  Meigs,  J,  K.  Mitchell, 
Dickson,  Pancoast,  Miitter,  the  Grosses,  Brinton,  Da  Costa,  whose 
worthy,  living  successors  will  not  deem  it  invidious  if  I  add  to  this  in- 
complete list  the  name  of  that  leader  of  American  surgery,  their  absent 
colleague.  Keen,  who,  resting  from  his  many  years  of  brilliant  and  suc- 
cessful work  in  behalf  of  this  college,  will  in  a  distant  land  be  glad  with 
us  to-day. 

The  Jefferson  Medical  College  is  indeed  singularly  fortunate  in  the 
possession  of  this  large  general  hospital,  admirable  in  construction  and 
arrangement,  entirely  under  the  administration  of  a  single  board  of 
trustees  common  to  the  college  and  the  hospital,  who  control  all  of  the 
appointments  to  the  hospital  staff  and  who  in  serving  the  best  interests 

^Address  at  the  opening  of  the  new  Jefferson  Medical  College  Hospital, 
June  7,  1907.  Published  in  The  Journal  of  the  American  Medical  Association, 
August  17,  1907. 

183 


184  MEDICAL   BESEAECn   AND    EDUCATION 

of  the  patients  are  in  the  fullest  sympathy  with  the  needs  of  medical 
education  and  active  in  its  promotion.  It  is  precisely  the  lack  of 
hospitals  under  the  control  of  our  medical  schools  which  constitutes  one 
of  the  most  serious  obstacles  in  the  development  of  medical  education 
in  this  country,  and  all  interested  in  the  advancement  of  medical  science 
and  teaching  in  America  have  reason  to  be  grateful  to  the  State  of 
Pennsylvania  and  the  private  benefactors  whose  enlightened  generosity 
has  made  possible  this  enviable  possession  of  the  Jefferson  Medical 
College. 

The  theme  of  my  remarks  on  this  occasion — the  relation  of  the 
hospital  to  medical  education  and  medical  research — is  naturally  sug- 
gested by  the  event  which  we  are  assembled  to  celebrate. 

The  discussion  of  the  problems  of  clinical  teaching  and  investiga- 
tion by  one  engaged  in  laboratory  work,  although  actively  interested  in 
all  that  pertains  to  the  advancement  of  medical  education,  may  have 
the  advantage,  so  useful  to  a  speaker,  of  a  certain  detachment  of  view, 
of  length,  if  not  clearness,  of  perspective,  and  of  the  absence  of  too 
disturbing  a  consciousness  of  all  the  difficulties  inherent  in  the  working 
out  of  details. 

It  would  be  interesting  to  trace  the  evolution  of  methods  of  clinical 
instruction  from  their  inception,  or  rather  revivdl,  in  Padua  by  Mon- 
tanus  about  the  middle  of  the  sixteenth  century  to  the  present  time. 
"We  should  follow  the  conveyance  of  these  methods  by  the  elder  van 
Heurne  toward  the  end  of  the  sixteenth  century  from  Padua  to  Leyden,, 
where  in  the  course  of  a  century  they  reached  the  high  development 
attained  under  the  great  Boerhaave,  communis  Europce  preceptor,  and 
whence  influences,  spreading  in  the  eighteenth  century  first  to  Got- 
tingen,  Halle,  Vienna,  and  Edinburgh,  can  be  traced  continuously  down 
to  this  very  day  and  to  the  medical  schools  of  America.  But  such  a 
historical  survey,  hitherto  imperfectly  drawn,  is  a  theme  by  itself,  which 
I  must  forego,  although  commending  it  as  an  attractive  one  to  medical 
historians. 

"While  the  early  history  of  medical  education  in  this  country  is  a 
story  of  feeble  resources,  but  still  of  high  endeavor  and  of  just  apprecia- 
tion of  the  requirements  of  training  for  a  learned  profession,  we  can  not 
contemplate  with  similar  satisfaction  and  pride  the  deplorable  period 
which  followed  through  many  years  of  lowered  standards  of  preliminary 
education,  of  shortened  courses,  and  of  faulty  arrangement  of  the  cur- 


TEE   HOSPITAL  185 

riciilum.  N'evertheless,  these  unfortunate  conditions,  attributable 
mainly  to  the  circumstances  of  rapid,  pioneer  development  of  the 
country  and  to  the  absence  of  any  responsible  supervision  outside  of  the 
medical  schools,  were  saved  from  giving  results  as  bad  as  they  are  often 
depicted  and  as  the  system  seemed  to  demand  by  a  measure  of  practical, 
clinical  instruction,  by  the  high  character  and  gifts  of  many  of  the 
teachers,  and  by  the  preservation  of  sound  traditions  of  the  physician's 
calling. 

Xothing  is  more  remarkable  in  the  history  of  medical  education  in 
this  country  than  the  rapidity  with  which  our  better  schools  have 
emerged  in  the  last  two  decades  from  this  low  state.  Especially  note- 
worthy during  this  period  is  the  development  in  these  schools  of  labora- 
tory teaching  from  the  weakest  to  the  strongest  position  in  the  cur- 
riculum, with  the  corresponding  and  most  gratifying  growth  in  this 
country  of  the  sciences  of  anatomy,  physiology,  pathology,  biologic 
chemistry,  pharmacology  and  bacteriology.  Hygiene,  unfortunately, 
has  lagged  behind,  mainly,  I  believe,  through  lack  of  careers  for  trained 
hygienists  in  this  country,  especially  on  our  boards  of  health. 

The  introduction  and  development  of  laboratory  teaching  has  had  a 
profound  influence  on  our  ideas  of  methods  of  medical  education.  In 
the  laboratory  knowledge  is  acquired  not  by  reading  or  being  told  about 
things  or  even  by  seeing  them  demonstrated  by  another,  but  by  im- 
mediate contact  with  the  object  of  study,  by  power  to  use  technical 
instruments  and  procedures,  and  by  personal  observation  and  experi- 
ment. A  final  adjustment  has  not  yet  been  reached  between  this  prac- 
tical method  of  acqiiiring  knowledge  and  the  older  didactic  or  exposi- 
tory method,  to  which  within  proper  restraints  I  am  not  unfriendly,  but 
the  days  of  dominance  of  didactic  teaching  in  our  medical  schools  are 
numbered. 

A  pertinent  inquiry  in  this  connection  is  whether  improvement  in 
the  teaching  of  medicine  and  surgery  has  kept  pace  with  that  of  the 
laboratory  subjects.  Improvement  in  the  former  there  has  been,  but  it 
is,  nevertheless,  true  that  the  so-called  theoretical  subjects  are  to-day 
taught  most  practically  and  the  so-called  practical  branches  most  theo- 
retically. It  is  above  all  familiarity  with  the  methods  and  results  of 
teaching  in  the  laboratory  which  has  emphasized  this  contrast  and  has 
indicated  directions  of  improvement.  Such  contrasts,  however,  as  those 
implied  in  the  distinctions  so  commonly  drawn  between  theoretical  or 


186  MEDICAL  BESEABCH   AND   EDUCATION 

scientific  subjects  on  the  one  hand  and  practical  subjects  on  the  other 
in  the  medical  curriculum,  and  between  the  methods  of  teaching  in  the 
laboratory  and  those  of  teaching  in  the  hospital  are  unfortunate  and 
not  inherent  in  the  nature  of  the  subjects.  Both  classes  of  subjects  are 
practical  in  that  they  admit  of  application  to  practical  use  and  in  that 
their  common  aim  is  to  serve  the  training  of  practitioners,  and  both 
are  scientific  in  that  they  rest  on  and  are  furthered  by  coordinated 
knowledge  gained  by  systematic  observation,  experiment  and  reasoning. 
The  justification  for  the  presence  of  any  obligatory  subject  in  the 
medical  curriculum  and  for  the  amount  of  time  devoted  to  it  is  its 
importance  for  the  training  of  sound  practitioners  of  medicine  and 
surgery.  Nor  should  there  be  any  difference  in  the  general  principles 
underlying  the  methods  of  teaching  the  laboratory  subjects  and  those  of 
teaching  the  clinical  branches.  For  the  latter  the  hospital  is  the  labora- 
tory where  the  results  of  Nature's  experiments  are  to  be  studied  and 
alleviated  by  the  methods  of  science. 

Training  in  the  laboratories  in  the  early  years  of  the  medical  course 
should  be  a  preparation  for  the  final  work  in  the  hospital  where  the 
ultimate  goal  of  medical  education  is  approached — the  ability  to  in- 
terpret and  to  forecast,  and  the  power  to  prevent,  to  remove  or  to  relieve 
the  manifestations  of  disease  and  injury.  Important  as  clinical  teach- 
ing must  have  been  even  in  the  relatively  undeveloped  state  of  medicine 
and  surgery  in  past  centuries,  it  is  vastly  more  important  in  these  days 
of  accumulated  medical  knowledge  and  experience,  of  refined  methods  of 
diagnosis  by  physical  examination  and  by  a  multitude  of  technical  pro- 
cedures, and  of  improved  methods  of  medical  and  surgical  treatment. 

Do  the  methods  of  teaching  the  clinical  subjects  generally  adopted 
in  our  medical  schools  at  the  present  time  bring  the  student  suflBciently 
into  that  intimate,  prolonged,  personal  contact  with  the  object  of  study, 
in  this  case  the  living  patient,  which  secures  that  abiding,  vital,  useful 
knowledge,  the  possession  of  which  alone  is  power  for  good,  and  the  lack 
of  which  is  helplessness  and  even  power  for  harm?  As  I  have  inti- 
mated, I  believe  that  the  clinic  falls  behind  the  laboratory  in  this  regard, 
and  that  the  greatest  strength  of  the  curriculum  is  not  where  it  should 
lie. 

It  is  not  many  years  since  practically  the  sole  method  of  clinical 
teaching  in  the  medical  schools  of  this  country  was  the  amphitheater 
clinic.     Not  a  word  need  be  said  against  the  value  of  this  important 


THE    HOSPITAL  187 

form  of  clinical  instruction,  but  no  argument  is  needed  to  show  that  by 
itself  it  does  not  suffice  for  the  practical  training  of  students  in  the 
science  and  art  of  medicine. 

A  distinct  advance  was  marked  by  the  introduction  in  recent  years  ■ 
of  the  system  of  ward  classes,  by  which  students  in  groups  are  admitted 
to  the  hospital  wards  and  given  opportunities  to  examine  patients  and  to 
receive  personal  instruction.  It  is  not  necessary  for  my  present  purpose 
to  discuss  the  various  forms  of  these  ward  classes  or  the  methods  of 
conducting  them,  or  similar  classes  for  practical,  clinical  instruction,  or 
to  point  out  in  detail  their  great  value  to  the  student,  which  is  uni- 
versally recognized. 

Neither  the  amphitheater  clinic  nor  the  ward  class  meeting  under 
an  instructor  at  stated  hours  and  for  short  periods  of  time,  useful  as  they 
are,  represents  the  full  ideal  of  the  laboratory  method  of  teaching. 
They  correspond  rather  to  demonstrative  courses,  which  have  their  own 
place  and  value.  Such  courses  alone  would  represent  the  attempt  to 
teach  a  subject  like  bacteriology  by  demonstrations  of  methods,  cultures 
and  microscopic  slides  instead  of  having  the  student  make  his  own 
media,  plant  and  cultivate  the  bacteria  by  his  own  hands,  and  follow  and 
study  from  day  to  day  with  his  own  eyes  the  characters  of  the  growing 
organisms.  It  is  only  by  the  latter  method  that  bacteriologists  are 
made  and  it  is  only  by  a  similar  method  that  capable  practitioners  of 
medicine  and  surgery  can  be  made,  and  if  this  essential  training  is  not 
at  least  begun  in  the  undergraduate  days  in  the  medical  school,  it  must 
be  secured,  if  at  all,  later,  often  under  disadvantageous  circumstances 
and  at  great  cost  both  to  patient  and  to  physician. 

This  kind  of  clinical  training  means  practical  work  in  the  dispensary 
and  especially  that  students  in  their  final  year  of  study  have  patients 
assigned  to  them  in  the  public  wards  of  the  hospital,  where  under  proper 
restrictions  they  can  freely  come  and  go,  that  they  take  histories,  make 
necessary  examinations  for  diagnosis,  follow  the  course  of  disease  from 
day  to  day  and  become  familiar  with  methods  and  results  of  treatment, 
all  of  this  work  being,  of  course,  under  competent  supervision  and  under- 
taken only  after  suitable  preliminary  studies.  Privileges  and  opportuni- 
ties for  practical  training  of  the  kind  indicated  are  at  present  enjoyed  in 
most  of  our  hospitals  only  by  the  fortunate  internes,  but  the  system  is 
familiar  in  Great  Britain  as  that  of  clinical  clerks  and  surgical  dressers, 
and  in  Germany  as  that  of  PraMikanten,  hospital  service  in  this  capacity 


188  MEDICAL   RESEAECE   AND    EDUCATION 

being  a  requirement  in  these  countries  for  admission  to  examinations 
for  the  license  to  practise.  The  system  has  been  in  successful  operation 
at  the  Johns  Hopkins  Hospital  since  the  opening  of  the  medical  school. 

It  should  be  emphasized  that  the  system,  unlike  that  of  ward  classes, 
constitutes  a  part  of  the  regular,  orderly  machinery  of  the  hospital,  that 
the  students  do  work  important  for  the  interests  of  the  patient  and 
which,  if  not  done  by  them,  would  have  to  be  done  by  others.  How 
important  this  kind  of  clinical  training  is  deemed  by  that  country  which 
has  long  held  the  leadership  of  medical  science  is  indicated  by  the 
recent  addition  in  Germany  to  the  formerly  required  period  of  study  of 
the  so-called  practical  year  of  continuous  service  in  a  hospital  before  the 
student  is  eligible  for  the  license  to  practise. 

I  believe  that  it  is  incumbent  on  our  medical  schools  and  public 
hospitals  to  furnish  students  with  opportunities  for  the  kind  of  clinical 
training  which  I  have  briefly  sketched  and  have  indicated  as  com- 
parable to  the  laboratory  method  of  teaching.  Let  us  briefly  consider 
,  what  objections  can  be  urged  against  this  method  of  clinical  training 
and  what  obstacles  stand  in  the  way  of  its  general  adoption  in  this 
country. 

The  difficulties  are  not  to  be  sought  primarily  in  the  lack  of  desire 
or  willingness  on  the  part  of  medical  schools  to  advance  along  these  lines 
of  improved  clinical  teaching.  It  may  be  that  the  advantages  of  the 
newer  methods  are  not  so  widely  and  fully  appreciated  as  is  to  be 
desired,  but  the  leaders  and  especially  the  younger  generation  of  clinical 
teachers  are  alive  to  the  importance  of  reform. 

The  difficulties  and  objections  come  from  that  other  essential  arm 
of  medical  education — the  hospitals.  Under  the  prevailing  system  of 
medical  education  in  this  country  the  most  valuable  asset  of  a  medical 
school  is  the  possession  of  an  endowed,  good  general  hospital,  the  ap- 
pointments to  which  are  controlled  by  the  school  and  a  main  purpose  of 
which  is  to  serve  the  interests  of  medical  education,  while  serving  the 
best  interests  of  the  patients.  There  are  few  hospitals  which  stand  in 
this  relation  to  a  medical  school  and  of  these  still  fewer  capable  of 
furnishing  the  requisite  clinical  opportunities,  for  it  is  self-evident  that 
the  system  of  ward  work  which  I  have  outlined  is  practicable  only  when 
the  ratio  between  the  number  of  patients  and  the  number  of  students 
does  not  fall  below  certain  limits. 

Most  of  our  schools  must  look  to  outside  public  hospitals  to  aid 


THE   HOSPITAL  189 

them  in  this  most  important  part  of  the  training  of  medical  students, 
and  the  appeal  of  the  schools  and  the  students,  an  appeal  which  should 
be  supported  by  the  entire  medical  profession,  is  one  which  should 
receive  the  most  careful  consideration  from  the  trustees  of  these 
hospitals.  The  source  of  the  appeal  should  be  heeded.  Our  medical 
charities  could  not  exist  without  the  free  gift  of  their  services  by 
physicians,  and  the  mere  pecuniary  value  of  these  services,  amounting 
annually  to  many  millions  of  dollars,  exceeds  that  of  all  the  funds  con- 
tributed to  their  endowment.  The  welfare  of  the  community  is  vitally 
concerned  with  the  supply  of  well-trained  physicians,  never  so  much  so 
as  to-day  when  the  power  to  relieve  suffering  and  to  check  the  incal- 
culable waste  to  society  from  preventable  disease  has  been  greatly  in- 
creased and  is  constantly  growing.  If  the  public  wants  good  doctors 
it  must  help  to  make  them. 

A  hospital  which  includes,  as  most  public  hospitals  do,  among  its 
recognized  legitimate  functions  not  only  the  care  of  the  poor  sick,  but 
also  the  training  of  physicians  and  nurses  and  the  advancement  and 
dissemination  of  medical  knowledge,  adds  no  function  which  is  new  in 
principle  when  it  admits  advanced  undergraduate  students  to  work  in 
its  wards,  while  by  so  doing  it  greatly  increases  its  usefulness  and  serv- 
ice to  the  community,  and  I  believe  also  the  patients.  There  is  no 
very  material  difference  between  the  qualifications  of  these  advanced 
students  to  undertake  this  work  and  the  qualifications  of  internes  when 
first  admitted  to  the  hospital  staff.  The  introduction  of  these  students 
into  the  hospital  in  accordance  with  the  plan  of  ward  work  recom- 
mended interferes  in  no  way  with  the  orderly  discipline  and  quiet  of 
the  wards. 

The  objection  concerning  which  the  greatest  misapprehension  exists 
and  which  doubtless  weighs  heaviest  in  the  minds  of  managers  of 
hospitals  and  of  the  lay  public,  unfamiliar  with  the  actual  facts,  is  the 
fear  that  harm  will  be  done  to  the  patients  by  permitting  them  to  be 
examined  by  students.  The  primary  purpose  of  the  hospital  is,  of 
course,  the  care  and  treatment  of  the  patients  and  the  first  duty  of 
hospital  trustees  and  physicians  is  to  the  patient.  Nothing  which 
prejudices  the  welfare  of  the  patient  can  for  a  moment  be  permitted, 
and  if  it  were  true  that  the  kind  of  clinical  training  which  I  am 
advocating  inflicted  any  injury  whatever  on  the  patient,  no  other  con- 
siderations could  outweigh  this  objection. 


190  MEDICAL   BESEAECH   AND   EDUCATION 

The  objection,  however,  is  entirely  unfounded.  Every  one  ac- 
quainted with  the  conditions  knows  that  our  clinical  teachers  and  the 
attending  physicians  and  surgeons  of  hospitals  are  keenly  solicitous  for 
all  that  conduces  to  the  comfort  of  their  patients  and  makes  for  their 
recovery,  every  whit  as  much  so  for  the  poor  as  for  the  rich.  They 
can  be  safely  trusted  to  take  every  precaution  to  guard  patients  from 
harm  and  to  imbue  their  students  from  the  start  with  the  same  spirit 
of  anxious  solicitude  for  the  welfare  of  the  patients,  A  main  purpose 
of  the  kind  of  clinical  training  under  consideration  is  precisely  to  teach 
students  when  and  how  to  examine  patients,  and  I  am  informed  by  my 
clinical  colleagues  that  students  are,  if  anything,  overcautious  in  their 
anxiety  to  refrain  from  any  possibly  injurious  disturbance  of  the  patient 
and  that  they  carefully  observe  any  directions  which  may  be  given  re- 
garding patients.  Your  own  Dr.  Keen  in  his  admirable  presidential 
address  to  the  Congress  of  American  Physicians  and  Surgeons  on  "  The 
Duties  and  Eesponsibilities  of  the  Trustees  of  Public  Medical  Institu- 
tions" expressed  himself  on  this  point  of  possible  harm  to  the  patient 
from  bedside  instruction  in  these  forcible  words : 

I  speak  after  an  experience  of  nearly  forty  years  as  a  surgeon  to  a  half- 
dozen  hospitals  and  can  confidently  say  that  I  have  never  known  a  single  patient 
injured  or  his  chances  of  recovery  lessened  by  such  teaching. 

So  far  from  being  detrimental,  the  teaching  of  physicians  and 
students  is  distinctly  advantageous  to  a  hospital  and  its  patients.  The 
teaching  hospital  is  in  general  more  influential,  more  widely  useful  and 
more  productive  in  contributions  to  medical  knowledge  than  a  hospital 
not  concerned  with  teaching.  Such  a  hospital  is  more  attractive  to 
physicians  and  surgeons  of  distinction  and,  therefore,  more  likely  to  be 
able  to  attach  such  men  to  its  attending  staff,  and  thereby  secure  the 
best  medical  service.  The  stimulating  influence  of  eager,  alert  students 
on  the  clinical  teachers  in  hospitals  has  been  so  delightfully  depicted  by 
Dr.  Keen  in  the  address  just  cited,  and  which  should  be  widely  read  by 
trustees  and  physicians,  that  I  can  not  refrain  from  quoting  his  re- 
marks on  this  point  in  full.     He  says : 

Moreover  trustees  may  overlook  one  important  advantage  of  a  teaching 
hospital.  Who  will  be  least  slovenly  and  careless  in  his  duties,  he  who  prescribes 
in  the  solitude  of  the  sick  chamber  and  operates  with  two  or  three  assistants  only, 
or  he  whose  every  movement  is  eagerly  watched  by  hundreds  of  eyes,  alert  to 
detect  every  false  step,  the  omission  of  an  important  clinical  laboratory  investi- 
gation, the  neglect  of  the  careful  examination  of  the  back  as  well  as  of  the  front 
of  the  chest,  the  failure  to  detect  any  important  physical  sign  or  symptom?    Who 


THE   HOSPITAL  191 

will  be  most  certain  to  keep  up  with  the  progress  of  medical  science,  he  who 
works  alone  with  no  one  to  discover  his  ignorance;  or  he  who  is  surrounded  by  a 
lot  of  bright  young  fellows  who  have  read  the  last  Lancet  or  the  newest  Annals 
of  Surgery,  and  can  trip  him  up  if  he  is  not  abreast  of  the  times?  I  always  feel 
at  the  Jefferson  Hospital  as  if  I  were  on  the  run  with  a  pack  of  lively  dogs  at 
my  heels.  I  can  not  afford  to  have  the  youngsters  familiar  with  operations, 
means  of  investigation  or  newer  methods  of  treatment  of  which  I  am  ignorant. 
I  must  perforce  study,  read,  catalogue  and  remember,  or  give  place  to  others 
who  will.     Students  are  the  best  whip  and  spur  I  know. 

There  is  no  teacher  who  will  not  subscribe  to  these  words  of  Dr. 
Keen. 

It  should  furthermore  be  emphasized  that  the  efficiency  of  the  teach- 
ing hospital  in  its  main  function  of  treating  diseased  and  injured 
patients  is  increased  not  only  by  securing  the  most  skilful  medical  staff, 
by  the  constant  stimulus  of  their  interest  and  activity  and  by  the  spirit 
pervading  the  institution,  but  also  by  the  participation  of  advanced 
students  in  the  work  of  the  dispensary  and  the  wards  in  accordance 
with  the  system  of  clinical  training  which  I  am  urging  on  your  atten- 
tion. When  one  considers  all  the  time-consuming  microscopic,  chemical 
and  physical  tests  applied  in  modern  diagnosis  and  necessary  to  secure 
complete  records  of  cases  of  disease,  it  can  be  readily  understood  that  the 
increased  force  of  those  trained  to  make  these  examinations  conduces  to 
more  accurate  diagnosis,  and  to  more  satisfactory  control  of  the  progress 
of  the  patient  from  day  to  day,  and  therefore  to  better  treatment.  In 
advocating  improved  methods  of  clinical  training  and  the  introduction 
of  such  training  more  generally  into  public  hospitals  I  plead  and  plead 
earnestly  for  the  student,  but  I  plead  also  for  the  hospital  and  the 
patient. 

It  is  really  lamentable  to  contemplate  the  immense  clinical  material 
which  exists  in  the  public  hospitals  of  our  large  cities  and  which  could 
be  made  available  for  the  education  of  students  and  physicians  and  for 
the  advancement  of  medical  knowledge,  but  which  is  utilized  for  these 
purposes  either  not  at  all  or  very  inadequately.  Medical  schools  of  these 
cities  do  not  begin  to  secure  the  advantages  of  location  which  right- 
fully belong  to  them  and  they  allow  themselves  to  be  outstripped  by 
schools  less  favorably  situated  and  the  hospitals  themselves  are  less 
useful  than  would  otherwise  be  the  case. 

I  am  well  aware  of  the  practical  difficulties  in  establishing  the  neces- 
sary relations  with  hospitals  not  already  connected  with  medical  schools. 
These   difficulties,   however,   are  not  insurmountable   if  the  trustees. 


192  MEDICAL   BESEAECH   AND    EDUCATION 

teachers  and  medical  staff  sincerely  desire  their  removal.  The  new 
order  doubtless  involves  readjustment  of  existing  conditions  both  in  the 
schools  and  in  the  hospitals  concerned.  In  many  instances  there  will 
follow  a  considerable  increase  of  the  force  of  clinical  teachers  and  a 
wider  recognition  of  work  done  outside  of  the  college  walls  and  of  the 
immediate  direction  of  members  of  the  faculty,  a  recognition,  it  may  be, 
of  something  on  the  order  of  the  Scottish  extramural  teaching  or  of  the 
German  privat-docent  system,  but  adapted  to  our  own  special  conditions. 
Careers  will  be  opened  to  hospital  physicians  and  surgeons,  especially  to 
young  men,  ready  and  fitted  to  teach  but  who  now  find  the  doors  closed 
to  them. 

My  remarks  thus  far  have  related  mainly  to  the  needs  of  under- 
graduate medical  students  and  to  methods  of  undergraduate  clinical 
teaching.  Education  at  best  is  only  begun  in  the  school,  and  the  most 
the  medical  school  can  hope  to  do  is  to  send  its  graduates  forth  fitted 
to  begin  their  professional  work  and  to  continue  their  lifelong  educa- 
tion with  the  greatest  advantage  to  themselves  and  to  others.  I  have 
on  another  occasion  discussed  the  serious  lack  of  opportunities  in  this 
country  for  the  training  of  young  men  who  aim  at  the  higher  careers 
in  clinical  medicine  and  surgery,  and  I  contrasted  these  opportunities 
with  similar  ones  now  open  in  our  laboratories  for  those  who  desire  to 
become  teachers,  investigators  or  directors  of  laboratories  of  anatomy, 
physiology,  pathology  or  other  medical  science.  Training  for  the 
higher  clinical  careers  requires  a  long  apprenticeship  after  graduation 
from  a  medical  school  and  after  the  ordinary  hospital  internship  and  is 
best  secured  by  prolonged  service  in  a  hospital  as  resident  physician  or 
surgeon  under  conditions  which  secure  more  thorough  practical  experi- 
ence and  better  opportunities  for  scientific  study  and  investigation  than 
those  which  now  exist  under  the  customary  arrangement  of  the  medical 
staff  of  our  hospitals.  I  shall  not  now  occupy  time  by  renewed  con- 
sideration of  this  aspect  of  my  subject  further  than  to  state  my  belief 
that  the  reorganization  of  the  resident  and  interne  medical  staff  of  the 
hospital  indicated  for  this  higher  training  of  graduates  of  medicine  is 
also  that  best  adapted,  if  not  essential,  for  the  successful  operation  of 
the  system  of  ward  work  for  undergraduates  which  I  have  sketched  and 
for  the  highest  efficiency  of  the  hospital. 

A  teaching  hospital,  such  as  the  new  Jefferson  Medical  College 
Hospital,  will  not  be  content  solely  with  making  the  best  possible 


THE   HOSPITAL  193 

provision  for  the  treatment  of  injury  and  disease  and  for  imparting 
knowledge,  it  will  recognize  as  one  of  its  most  important  functions  also 
the  increase  of  knowledge.  Although  I  am  approaching  the  end  of  the 
time  allotted  to  this  address,  I  can  not  pass  this  subject  by  without 
reference,  albeit  necessarily  a  hurried  one. 

Por  purposes  of  accurate  diagnosis  and  treatment  by  modern 
methods  a  general  hospital  must  nowadays  be  supplied  with  no  small 
equipment  for  clinical  laboratory  examinations,  and  a  good  pathologic 
laboratory  is  now  generally  recognized  as  essential  to  such  a  hospital 
even  in  its  routine  work.  Practical  courses  in  the  clinical  laboratories 
are  among  the  most  valuable  additions  of  recent  years  to  the  medical 
curriculum. 

The  problems  of  disease  presented  by  living  patients  are  the  most 
difficult  and  complex  in  the  whole  range  of  the  physical  and  natural 
sciences.  Much  light  can  be  shed  on  them  by  investigations  conducted 
in  physiologic,  chemical,  pathologic,  pharmacologic  and  bacteriologic 
laboratories,  especially  by  experimentation  on  animals,  but  it  is  increas- 
ingly clear  that  the  scientific  study  of  many  of  these  problems  can  be 
undertaken  with  the  greatest  advantage  in  well-equipped,  special  labora- 
tories connected  with  the  hospital  clinics  and  in  charge  of  investigators 
trained  in  chemical,  physical  and  biologic  methods,  with  convenient 
access  to  the  material  for  study  and  in  close  touch  with  the  clinicians. 
I  may  cite  as  good  examples  of  such  laboratories  those  of  the  university 
clinic  in  Munich  under  the  direction  of  Professor  Friedrich  Miiller. 

The  familiar  analytical  and  statistical  study  of  cases  of  disease, 
based  on  simple  clinical  observations,  and  first  extensively  and  fruit- 
fully applied  by  the  great  Prench  clinicians  of  the  early  part  of  the  last 
century,  has  been  of  immense  service  to  medicine  and  will  continue  to  be 
of  service.  A  good  clinical  observation  has  precisely  the  same  scientific 
value  as  a  fact  demonstrated  in  the  laboratory,  and,  even  if  more  difficult 
of  interpretation,  is  often  the  safer  guide  for  the  action  of  the  physician. 

It  is,  however,  from  the  special  clinical  laboratories  that  we  may 
reasonably  hope  for  a  more  penetrating  insight  into  the  causes  and 
nature  of  many  diseases,  an  insight  which  perhaps  may  arm  physicians 
with  a  saving  power  of  prevention  and  treatment  of  some  of  the  organic 
diseases  of  advancing  life  comparable  to  the  inestimable  gifts  of 
bacteriologic  laboratories  to  the  prevention  and  treatment  of  infectious 
diseases.     We  must  welcome  the  establishment  of  such  laboratories  and 

14 


194  MEDICAL   BESEABCH   AND   EDUCATION 

the  new  directions  which  they  are  giving  to  medical  research.  When 
the  purposes  of  such  laboratories  are  made  clear,  their  foundation  and 
support  should  make  an  especially  strong  appeal  to  public  and  private 
philanthropy. 

The  medical  laboratories  of  whatever  kind  and  the  clinics,  while  each 
must  cultivate  its  own  special  field,  are  fundamentally  one  domain,  one 
in  their  scientific  methods  and  spirit  and  one  in  their  common  purpose 
to  advance  medical  knowledge  and  thereby  bring  healing  to  the  nations. 

In  this  great  domain  and  with  this  high  mission  may  the  Jefferson 
Medical  College  and  Hospital,  with  their  past  of  honorable  achievement 
and  their  future  of  larger  opportunities,  grow  and  prosper,  serving  skil- 
fully the  sick  under  their  care,  and  blessed  with  wise  counselors,  with 
able  and  devoted  teachers  and  contributors  to  medical  science  and  art, 
with  zealous  students  from  far  and  near,  and  with  loyal  graduates — an 
institution  standing  in  this  community  and  throughout  the  land  as  a 
powerful  influence  for  all  that  is  best  in  our  profession ! 


THE  MEDICAL  SCHOOL  AS  PAET  OF  THE  UNIVERSITY^ 

By  W.  H.  Howell,  M.D.,  Ph.D.,  LL.D. 
Peofessoe  of  Pht*siology,  The  Johns  Hopkins  Univeesity 

In"  our  educational  systems,  as  in  most  of  the  complex  institutions 
of  human  origin,  the  changes  that  are  constantly  occurring  do  not  seem 
to  follow  a  course  of  continuous  symmetrical  development.  The  manner 
of  growth  appears  to  resemble  rather  that  process  of  exuviation  with 
which  we  have  been  made  familiar  in  the  life  history  of  the  humble 
crab  and  his  crustacean  relatives.  That  is  to  say,  at  certain  more  or 
less  regular  periods  our  systems  become  enveloped  in  a  case  of  customs 
and  traditions  of  shelly  consistency,  which,  while  it  serves  as  a  protec- 
tion against  dangers  from  without,  afflicts  greviously  by  and  by  the 
growing  parts  within.  In  the  end  the  increasing  pressure  becomes  dis- 
tressing or  painful  and  the  only  way  out  of  the  predicament  is  to 
molt  the  old  shell  and  grow  as  fast  as  possible  before  a  new  one  takea 
its  place.  The  system  of  education  in  medicine  has  in  fact  been  under- 
going a  molt  for  some  years  past  and  what  I  have  in  mind  to-day  is 
to  call  attention  to  the  fact,  perhaps  already  sufficiently  obvious,  that 
the  process  is  not  entirely  completed.  While  certain  parts  of  the 
system  are  free  from  the  old  constricting  influences  and  are  at  liberty 
to  grow  and  expand  in  proportion  to  the  measure  of  vitality  with  which 
they  are  endowed,  other  parts  are  still  encased  in  ancient  shell  which 
serves  as  an  obstacle  to  their  proper  development. 

During  the  last  twenty  years  especially  medical  education  and  the 
condition  of  medicine  in  general  in  this  country  have  been  the  subjects 
of  much  earnest  discussion.  Critics  within  and  without  the  profession 
have  exposed  its  weakness  in  the  merciless  way  appropriate  to  their 
role,  and  reformers  have  cried  aloud  its  deficiencies  from  the  house-tops. 
One  naturally  inquires  what  is  the  cause  of  all  this  stir?  What  has 
happened  to  create  such  dissatisfaction  with  a  system  that  formerly 
was  accepted  without  comment?  The  ills  and  accidents  which  afflict 
mankind  are  not  greater  or  more  numerous  than  in  former  times.    The 

^  Annual  address  in  Medicine,  Yale  University.     Published  in  Science,  July 
30,  1909. 

195 


196  MEDICAL  HESEABCH   AND   EDUCATION 

pestilence  still  walks  in  darkness  and  destruction  wastes  at  noonday  as 
of  old,  but  not  more  so.  Indeed  we  flatter  ourselves  that  we  are  better 
off  than  our  ancestors  in  these  regards.  But  we  take  a  different  attitude 
toward  them.  Our  forefathers  did  what  they  could  to  escape  these  ills 
and  in  biblical  phrase  sought  to  their  physicians  with  more  or  less  satis- 
factory results.  But  what  they  could  not  avoid  or  prevent  they  accepted 
submissively  as  an  act  of  God,  a  phrase  which  some  one  has  defined  in 
comprehensive  manner  as  including  all  those  acts  which  no  reasonable 
man  can  foresee.  In  these  latter  days,  on  the  contrary,  there  is  a  wide- 
spread feeling  that  man  should  be  able  to  apply  his  intelligence  so  as  to 
reach  a  more  satisfactory  understanding  and  control  of  disease  and 
pestilence.  The  reason  for  this  change  of  attitude  toward  nature  is  to 
be  found,  without  doubt,  in  the  great  increase  in  our  scientific  knowl- 
edge. Physics,  chemistry  and  biology  have  added  immensely  to  our 
comprehension  of  the  processes  of  nature,  living  as  well  as  dead,  and 
this  acquisition  has  awakened  in  us  a  keen  desire  to  apply  all  this  knowl- 
edge practically  in  saving  ourselves  as  far  as  may  be  from  sickness  and 
death.  If  we  can  find  out  the  secrets  of  the  stars  and  bend  the  forces 
of  nature  to  our  use  and  pleasure,  can  we  not  also  unravel  to  some 
extent  those  mysteries  of  life  and  death  which  after  all  are  the  phe- 
nomena of  paramount  importance  to  us  in  this  universe  in  which  we 
find  ourselves  placed.  This  same  desire  to  apply  scientific  knowledge 
to  practical  medicine  was  apparent  in  Europe  early  in  the  nineteenth 
century.  Investigations  of  the  laws  controlling  inanimate  nature  had 
spread  rapidly  to  a  similar  study  of  the  properties  of  living  matter, 
although  the  transition  was  attended  by  some  convulsive  qualms  among 
the  timid  and  superstitious.  Foolish  and  ineffectual  attempts  were 
made  to  discourage  the  bold  pioneers  by  charges  of  impiety  or  by  pre- 
dictions of  the  necessary  futility  of  all  efforts  to  solve  such  great  mys- 
teries. In  medicine,  especially,  this  kind  of  opposition  was  very 
common,  and  the  enlightened  members  of  the  profession  contended 
against  many  unnecessary  difficulties  in  their  efforts  to  introduce  the 
methods  and  results  of  science  into  the  practise  of  medicine.  Our  own 
country  was  very  slow  in  feeling  the  effect  of  this  movement.  We  are 
all  aware  that  medical  education  and  therefore  medical  practise  in  this 
country,  speaking  in  general  terms,  were  until  recent  years  far  below 
the  standard  maintained  in  Europe.  Conditions  among  us,  in  fact, 
were  such  that  for  a  time  things  went  from  bad  to  worse.    Our  curve  of 


THE    MEDICAL    SCHOOL  197 

efficiency  kept  falling,  while  in  other  civilized  lands  it  rose  more  or  less 
parallel  with  the  growth  in  scientific  knowledge.  There  thus  came  to 
us  a  certain  distinct  and  admitted  inferiority  in  medical  matters  which 
has  not  yet  been  fully  overcome.  Many  excuses  and  reasons  might  be 
offered  for  the  backwardness  of  our  development  in  medicine,  but  the 
excuse  most  frequently  made  was  and  is  that  our  growing  country  has 
need  in  the  outlying  districts  for  an  inferior  type  of  physician  willing 
to  work  hard  for  little  pay,  and  consequently  entitled  to  receive  his 
degree  in  medicine  at  little  expense  of  time  or  money.  A  need  of  this 
kind  undoubtedly  existed,  but  it  scarcely  justified  the  creation  of  the 
numerous  poor  schools  with  which  this  country  was  afflicted,  and  whose 
ill-prepared  graduates  practised  in  the  centers  of  population  as  well  as 
in  the  outposts  of  civilization.  One  can  not  entirely  suppress  the  sus- 
picion that  motives  of  personal  gain  and  commercial  expediency  were 
largely  responsible  for  the  deplorable  condition  that  prevailed  in  the 
latter  half  of  the  nineteenth  century.  A  few  schools  possessed  of  good 
traditions  made  an  earnest  fight  for  better  things  under  very  adverse 
circumstances,  and  we  must  recognize  that  among  the  graduates  of  the 
poorer  schools  there  were  some  who  became  able  and  even  famous  prac- 
titioners. I  venture  to  believe  that  this  latter  result  was  in  no  way  due 
to  the  system,  but  is  to  be  explained  by  the  fact  that  the  profession  of 
medicine  will  always  draw  to  itself  a  considerable  number  of  able  and 
high-minded  men,  who  are  bound  to  make  themselves  felt  upon  what- 
ever system  their  education  may  be  conducted.  But  the  general  output 
of  medical  graduates  was  for  a  time  far  inferior  in  quality  to  that  sup- 
plied to  other  nations.  What  else  could  be  expected  from  a  system  which 
permitted,  indeed  actively  encouraged,  men  to  enter  the  medical  school 
without  any  previous  education  and  then  qualified  them  to  practise  upon 
the  public  after  a  bare  ten  or  twelve  months'  study  of  the  science  and  art 
of  medicine  ?  It  was  much  easier  at  one  time  to  enter  the  profession  of 
medicine  than  to  become  a  recognized  journeyman  in  a  trade.  The 
conditions  indeed  became  bad  enough  to  call  urgently  for  reform,  and 
this  call  has  grown  increasingly  imperative  down  to  the  present  day.  In 
a  democratic  country  like  ours  a  reform  in  a  system  of  education  is 
naturally  a  slow  process.  Under  a  more  centralized  form  of  government 
it  is  only  necessary  to  convince  the  few  who  have  authority  and  the 
desired  reform  may  be  inaugurated  promptly  and  effectively.  But 
with  us  it  is  requisite  to  arouse  the  people  at  large.    If  an  improvement 


198  MEDICAL   BESEABCH   AND   EDUCATION 

is  called  for  it  can  only  be  established  permanently  by  creating  an  en- 
lightened public  opinion  in  its  favor.  It  happens  therefore  in  medicine 
as  in  politics  that  the  country  gets  about  the  kind  of  service  that  the 
majority  thinks  it  wants,  and  progressive  leaders  have  a  very  hard  time 
in  making  that  majority  change  its  ideas.  Certainly  in  medicine  the 
effort  for  reform  has  been  a  long  and  laborious  one,  but  we  may  feel 
sure  that  now  the  tide  of  public  opinion  has  turned  in  favor  of  a  better 
system.  A  necessary  preliminary  step  was  the  development  of  an  appre- 
ciation of  science  in  this  country.  Fortunately  our  colleges  and  uni- 
versities have  made  splendid  progress  in  this  respect.  They  have 
created  a  scientific  atmosphere,  they  have  let  loose  among  us  a  scientific 
spirit  which  has  entered  like  a  ferment  into  the  medical  schools.  There, 
like  a  ferment,  it  has  caused  much  commotion  and  unrest  of  a  healthy 
and  normal  kind,  the  end-result  of  which  will  be  no  doubt  the  estab- 
lishment of  a  system  of  medical  training  as  good  at  least  as  that 
found  in  other  countries  of  the  same  grade  of  civilization.  It  may 
be  interesting  to  inquire  how  far  we  have  advanced  toward  this 
desirable  end,  and  in  what  direction  our  present  tendencies  are 
taking  us.  The  positive  results  of  the  agitation  begun  during  the 
present  generation  are  important  and  satisfactory.  Our  schools,  if 
we  take  them  all  into  account,  are  still  so  heterogeneous  that  it  is 
scarcely  possible  to  make  any  general  statements  that  shall  be  equally 
applicable  to  all,  but  we  have  an  increasing  number  of  strong  schools 
which  are  setting  the  pace  for  the  rest,  and  those  that  can  not  keep  up 
will  have  to  drop  out  of  the  race  altogether.  According  to  reports 
thirty  schools  surrendered  to  this  fate  during  the  past  five  years.  The 
better  schools,  which  we  need  alone  consider  in  this  matter  of  the  status 
of  our  development,  are  organized,  almost  without  exception,  as  the 
medical  department  of  a  university.  Herein  lies  the  secret  of  their 
success  and  the  promise  of  their  improvement  in  the  future.  In  these 
schools  there  is  firmly  established  a  four  years'  graded  course,  of  which 
the  first  two  years  are  devoted  largely  to  the  preparatory  medical 
sciences  of  anatomy,  physiology  and  pathology,  using  these  terms  in 
their  broad  sense  to  include  such  subjects  as  histology,  physiological 
chemistry,  pharmacology,  etc.  The  most  significant  fact,  however,  is 
that  these  preparatory  sciences  are  taught  by  specialists  who  give  their 
entire  time  to  the  work,  and  whose  methods  and  ideals  differ  in  no  essen- 
tial respect  from  those  followed  by  teachers  of  physics,  chemistry  and 


THE    MEDICAL    SCHOOL  .         199 

biology.  In  other  words,  the  instruction  in  these  medical  sciences  has 
been  raised  to  the  university  level,  as  has  been  the  case  now  for  so  many 
years  in  the  German  schools.  The  change  in  the  character  of  the  in- 
struction in  these  subjects  has  brought  it  about  that  in  many  of  our 
colleges  and  universities  they  are  accepted  as  appropriate  courses  for 
academic  degrees,  a  recognition  which  I  believe  will  soon  become 
general.  For  when  properly  taught  a  course  in  anatomy,  physiology  or 
pathology  gives  a  liberal  education  and  a  mental  training  which  are  of 
value  to  any  man,  whatever  may  be  his  career  in  after-life.  These  sub- 
jects deal  with  the  great  problems  of  existence,  the  riddles  of  life  and 
death  and  propagation,  and  all  the  properties  of  that  extraordinary  sub- 
stance which  we  call  living  matter ;  they  throw  light  not  only  on  the  spe- 
cial questions  that  interest  the  physician,  but  they  furnish  also  valuable 
material  for  the  practical  use  of  the  sociologist,  the  political  scientist, 
the  philanthropist  and  the  statesman.  Moreover,  they  bring  us  close  to 
the  highest  and  most  difficult  subject  that  the  human  mind  is  called 
upon  to  contemplate,  that  is  to  say,  the  relationship  between  ourselves 
and  the  material  universe,  the  ever-fascinating  and  mysterious  inter- 
dependence of  mind  and  matter.  Much  has  been  said  upon  the  subject 
of  the  cultural  value  of  liberal  studies  as  opposed  to  so-called  profes- 
sional or  technical  studies,  but  in  all  discussions  of  this  kind  there  is 
a  tendency  toward  a  certain  arbitrary  assumption  that  courses  of  studies 
must  fall  wholly  under  one  or  the  other  of  these  rubrics,  whereas  com- 
mon experience  teaches  us  that  merely  putting  a  label  upon  a  thing  is 
no  guaranty  that  the  contents  are  thereby  properly  described.  The 
preparatory  training  for  life  should  be  liberal  and  humanizing,  but  it  is 
quite  possible  that  many  different  lines  of  study  may  lend  themselves 
with  equal  success  to  the  development  of  these  qualities,  and  it  will  be 
admitted  perhaps  by  every  one  that  the  courses  of  study  in  college,  in 
addition  to  having  a  broadening  influence  upon  the  student,  should  also 
inculcate  in  him  some  specific  kind  of  mental  training  which  will  fit 
him  better  to  take  a  high  rank  in  whatever  career  he  may  happen  to 
select. 

The  term  technical,  as  applied  to  courses  of  instruction,  has  acquired 
an  unfortunate  connotation  which  implies  that  they  are  lacking  in  value 
from  the  standpoint  of  general  training.  As  a  matter  of  fact,  many 
of  the  graduate  courses  given  in  our  universities  are  quite  as  technical 
as  those  given  in  the  preparatory  sciences  in  the  medical  school,  and 


200  MEDICAL  BESEAECR   AND   EDUCATION 

for  one  as  for  the  other  it  is  short-sighted  to  assume  that  they  are  devoid 
of  a  general  educational  value.  I  prefer  much  the  definition  of  the  term 
technical  which  has  been  given  by  Professor  Karl  Pearson.  He  makes 
a  distinction  between  technical  and  professional  instruction,  or,  to  use 
his  precise  terms,  between  technical  education  and  professional  instruc- 
tion. Under  the  latter  term  he  includes  training  in  the  art  of  a  specific 
profession — that  kind  of  training  which  the  apprentice  gets  from  his 
master  in  the  specialized  methods  and  handicraft  peculiar  to  the  voca- 
tion— the  kind  of  training  which,  in  the  case  of  the  physician,  is  obtained 
in  the  wards  and  clinics  in  contact  with  patients.  By  technical  edu- 
cation, on  the  other  hand,  he  means  that  training  in  the  underlying 
subjects  of  a  profession  which  makes  for  the  development  and  strength- 
ening of  the  mental  faculties.  The  technical  education  of  the  physician 
in  this  sense  lies  in  the  physical  and  natural  sciences,  including  under 
the  latter  term  the  whole  range  of  the  biological  sciences.  Whether  any 
given  course  in  this  category  meets  Pearson's  definition  of  technical  edu- 
cation is  determined  by  asking  whether  it  "  provides  mental  training  for 
the  man  who  has  no  intention  of  professional  pursuits."  Judged  by 
this  standard,  we  may  understand  that  it  is  the  method  in  which  a 
science  is  taught  as  much  as  its  contents  which  determines  whether  or 
not  it  has  value  as  an  intellectual  preparation  for  life.  I  have  no  doubt 
that  various  subjects,  scientific  or  otherwise,  are  taught  at  times  within 
the  walls  of  the  universities  in  such  a  way  that  they  miss  the  larger  end 
and  confer  only  the  restricted  benefit  of  a  special  knowledge  which  is 
truly  professional  for  that  subject.  There  can  be,  however,  no  hesita- 
tion in  claiming  that  the  subjects  of  anatomy,  physiology  and  pathology 
as  they  are  taught  or  should  be  taught  in  our  best  medical  schools  are 
adapted  to  give  a  training  to  the  mind  as  broadening  and  as  generally 
beneficial  as  courses  in  physics,  chemistr}^,  biology  or  indeed  as  any  of 
our  university  courses  which  deal  with  special  departments  of  human 
knowledge.  So  far  as  graduate  instruction  is  concerned  this  conten- 
tion has  long  been  admitted  in  this  country,  and  the  subjects  we  are 
considering  are  listed  upon  the  programs  of  study  in  both  the  philosoph- 
ical and  the  medical  faculties.  In  later  years  many  colleges  have  gone  a 
step  farther  and  have  accepted  these  courses  as  part  of  a  general  scientific 
training  for  those  students  who  are  looking  forward  to  a  career  in 
medicine.  It  is  perhaps  only  a  matter  of  a  little  time  before  they  will 
be  admitted  to  the  same  standing  in  all  respects  as  the  other  sciences. 


EiCLCOiv^Ai-  Atoii. 


TEE    MEDICAL    SCHOOL  201 

that  is  to  say  they  will  be  considered  not  only  as  subjects  of  special 
medical  interest,  but  as  conveying  knowledge  of  the  widest  human  inter- 
est and  importance.  So  far  as  the  subjects  themselves  are  concerned 
they  enjoy  their  widest  opportunity  and  best  environment  when  the 
medical  school  forms  an  integral  part  of  the  university,  not  only  in 
organization,  but  in  location  as  well.  If  it  so  happens  that  geograph- 
ically the  medical  school  is  separated  from  the  rest  of  the  university  it 
is  not  a  matter  of  vital  importance,  so  far  as  I  can  see,  in  which  set  of 
buildings  these  subjects  are  taught,  provided  only  the  teachers  are  of  the 
right  sort.  This  opinion,  I  am  glad  to  say,  is  merely  by  way  of  con- 
firmation of  the  practise  that  is  actually  coming  to  be  established  among 
us.  When  these  subjects  are  segregated  with  the  clinical  branches  some- 
thing, no  doubt,  of  the  university  atmosphere  is  lacking ;  when  they  are 
separated  from  the  clinical  side  there  is  a  corresponding  loss  of  medical 
atmosphere.  Which  is  the  more  serious  loss,  or  whether  there  is  any 
material  difference  in  the  final  result,  it  is  difficult  to  say.  The  medical 
student  probably  values  more  highly  the  medical  surroundings.  They 
give  significance  to  the  things  that  he  is  learning  and  in  various 
informal  ways  they  furnish  him  with  opportunities  to  acquire  the  points 
of  view  and  the  methods  of  practical  medicine.  On  the  other  hand,  they 
have  the  disadvantage  of  distracting  and  diverting  some  students  from 
a  thorough  study  of  the  preparatory  sciences.  I  have  had  frequent 
occasion  to  observe  this  effect.  Some  of  our  medical  students  chafe 
under  this  prolonged  preparation,  forgetting  the  fact  that  it  is  an 
opportunity  which  may  never  come  to  them  again,  and  forgetting  also 
that  it  gives  them  the  badge,  the  impress  that  will  differentiate  them 
from  the  mere  empiric,  when  the  time  comes  for  them  to  compete  with 
their  fellow  practitioners.  To  the  teachers,  on  the  contrary,  partic- 
ularly if  they  belong  to  the  productive  type,  the  university  atmosphere 
is  perhaps  more  stimulating.  The  methods  and  ideals  of  these  teachers 
are  more  closely  related  to  those  of  the  university  professors  than  to 
those  of  their  clinical  colleagues.  For  while  research  is  valued  as  much 
perhaps  in  the  medical  department  as  in  the  philosophical  department, 
there  is  the  difference  that  in  medical  circles  the  reward  of  immediate 
appreciation  goes  chiefly  to  those  investigations  that  promise  to  have  a 
direct  practical  application.  The  medical  atmosphere  encourages  re- 
search by  the  sharp  stimulus  of  an  abundant  reward  for  practical  results. 
The  university  spirit  or  the  academic  spirit,  on  the  other  hand,  takes  the 


202  MEDICAL   EESEAECE   AND   EDUCATION 

wider  and  wiser  view  that  looks  beyond  the  immediately  useful  to  the 
large  results  that  may  be  expected  from  a  growth  of  knowledge  in 
general.  This  serener  atmosphere  forms  a  grateful  environment  for 
research,  and  in  the  long  run  no  doubt  it  produces  the  larger  harvest 
of  useful  knowledge.  Investigation  after  all  is  always  a  voluntary 
offering.  There  is  no  way  of  compelling  it  or  of  estimating  its  value  in 
terms  of  time  or  quantity,  and  men  who  investigate  do  not  like  to  be 
put  under  the  pressure  of  demonstrating  that  the  work  they  do  is  of 
immediate  importance  to  mankind.  They  prefer  to  study  those  prob- 
lems which  for  one  reason  or  another  have  aroused  their  interest.  Con- 
sidering the  complexity  of  nature,  especially  the  living  side  of  nature, 
and  remembering  how  difficult,  even  dangerous,  it  is  to  apply  knowl- 
edge that  is  incomplete,  the  rest  of  mankind  would  do  well  to  encourage 
in  every  way  the  little  band  of  investigators  whose  chief  ambition  and 
pleasure  in  life  is  simply  to  add  to  our  store  of  knowledge.  As  a  matter 
of  fact  mankind  generally  does  not  place  a  very  high  estimate  on  the 
work  of  these  disinterested  individuals  whose  labors  contribute  to  the 
common  good  rather  than  to  personal  gain,  although  history  teaches 
us  in  an  infinite  number  of  ways  that  on  the  work  of  such  men  depends 
in  large  measure  the  possibility  of  progress.  Perhaps  the  explanation 
lies  in  the  fact  that  the  good  these  men  do  comes  after  them,  it  benefits 
posterity  rather  than  the  present  generation,  and  we  are  inclined  to  let 
posterity  do  the  appreciating  as  well  as  the  benefiting.  But  this  is  a 
line  of  thought  aside  from  our  present  purpose.  The  conclusion  that  I 
wish  to  emphasize  is  simply  that  all  the  agitation  that  has  been  going 
on  in  medical  circles  during  the  past  two  decades  has  resulted  finally  in 
the  establishment  of  two  reforms  in  medical  education.  First,  the  pre- 
liminary training  for  entrance  upon  the  medical  career  has  been  greatly 
increased.  Starting  with  practically  nothing  at  all,  it  was  raised  first 
to  a  common-school  education,  then  to  a  high-school  education  and 
finally,  in  the  university  schools,  to  a  college  preparation,  partial  or  com- 
plete. Second,  in  the  medical  course  itself  the  work  of  the  first  two 
years  has  been  so  arranged  that  it  continues  the  traditions  and  methods 
of  the  university  in  the  study  of  the  so-called  underlying  medical 
sciences.  It  will  be  observed  that  these  two  important  results  have  to 
do  with  the  preparation  for  practical  medical  work.  On  the  old  system 
two  years  were  given  to  acquiring  a  sufficient  knowledge  of  the 
art  of  medicine.     As   scientific  knowledge   increased  and  penetrated 


TEE    MEDICAL    SCHOOL  203 

into  medicine  the  period  of  instruction  was  prolonged  to  four  years, 
or,  taking  into  account  all  of  the  necessary  preparation,  to  six  or 
eight  years,  but  all  of  this  additional  time  was  devoted  substan- 
tially to  preliminary  or  preparatory  training.  This  is  a  significant  fact. 
All  of  the  truly  art  side  of  medicine  or  of  any  other  profession  may  be 
acquired  on  the  apprenticeship  system,  without  any  previous  prepara- 
tion other  than  is  implied  in  a  basis  of  general  intelligence.  It  is  the 
scientific  side  of  medicine  which  calls  for  all  of  this  extensive  prelimi- 
nary training.  "Without  it  one  might  still  in  a  two  years'  course  make  a 
capable  practitioner,  to  use  a  distinction  made  long  ago  by  Magendie, 
but  not  a  scientific  physician.  The  difference  between  an  able  practi- 
tioner and  a  scientifically  trained  physician  is  not  so  striking  that  it 
can  be  appreciated  at  once  by  the  public  at  large.  The  difference  is 
there,  however,  and  eventually  it  means  everything  to  the  advancement 
of  medicine  to  recognize  this  difference  and  to  increase  it  by  every  means 
at  our  command,  whatever  cost  of  time  and  money  it  may  entail. 
Excellence  is  generally  the  thing  that  costs.  If  by  the  expenditure  of 
more  money  we  can  add  a  knot  or  two  to  the  speed  of  our  steamships 
we  know  that  it  pays  us  to  do  so,  and  if  by  longer  and  more  expensive 
training  the  efficiency  of  the  physician  may  be  increased  a  little,  the 
difference  is  worth  the  cost,  for  it  also  will  add  much  to  the  happiness 
and  prosperity  of  the  whole  community. 

The  content  of  the  curriculum  of  our  first  two  years,  and  the  char- 
acter of  the  instruction  given  during  that  period,  may  be  modified  more 
or  less  from  time  to  time.  It  may  be  expanded  or  more  probably  it  may 
be  simplified,  but  it  seems  to  me  that  our  system  of  medical  instruction 
in  this  country  is  committed  definitely  to  the  general  principle  that 
these  medical  sciences  shall  be  taught  as  the  other  sciences  in  the  uni- 
versity are  taught,  by  specialists  who  give  their  entire  time  to  the  work 
and  who  are  active  in  research  as  well  as  in  instruction.  The  force  of 
successful  example  will  compel  all  schools  to  follow  this  ij^Q.  But,  we 
may  ask,  is  there  no  change  that  is  desirable  in  the  system  of  instruc- 
tion in  the  clinical  branches?  This  is  a  question  which  ought  to  be 
discussed  by  clinicians  as  by  those  who  know  whereof  they  speak.  But 
it  is  a  general  truth,  perhaps,  that  reforms  in  teaching  do  not  usually 
originate  from  those  occupying  the  positions  in  which  changes  are  called 
for.  Feelings  of  personal  interest  or  loyalty  to  traditions  prevent  them 
from  seeing  clearly  the  defects  that  may  be  obvious  to  others.    It  comes 


201  MEDICAL  BESEABCH  AND   EDUCATION 

about,  therefore,  that  the  initial  impulse  to  reform  is  often  forced  upon 
us  by  criticism  from  without.  In  regard  to  the  teaching  of  the  clinical 
subjects  in  our  medical  schools  three  general  changes  have  been  sug- 
gested at  one  time  or  another  which  are  likely  to  come  up  for  serious  con- 
sideration in  the  immediate  future.  First,  shall  the  time  devoted  to  these 
subjects  under  the  auspices  of  the  medical  school  be  lengthened  ?  At  pres- 
ent the  usual  plan  is  to  give  two  years  to  this  side,  and  the  definite  sugges- 
tion made  is  that  a  third,  exclusively  hospital  year,  shall  be  added.  I  shall 
not  stop  to  discuss  this  question.  Our  graduates  themselves  realize  the 
value  of  this  additional  experience  and  in  increasing  numbers  every  year 
they  are  seeking  a  term  of  service  in  the  hospitals  before  entering  upon 
private  practise.  It  seems  to  me  most  probable  that  we  shall  find  it  advan- 
tageous to  follow  in  this  respect  the  example  set  for  us  by  the  older 
countries,  that  is  to  add  a  year  of  hospital  service  as  an  obligatory  part 
of  the  requirements  for  the  degree  in  medicine  or  for  the  license  to 
practise  medicine.  As  we  all  know,  this  change  has  been  strongly  recom- 
mended by  the  council  on  education  of  the  American  Medical  Associa- 
tion. Second,  there  is  much  complaint  from  many  sources,  particularly 
from  the  teachers  of  the  medical  sciences,  that  the  professors  of  the 
clinical  subjects  do  not  make  adequate  use  of  the  results  and  methods 
of  science  in  their  instruction.  What  is  the  use  of  giving  the  student  a 
scientific  training  if  the  man  who  instructs  him  in  diagnosis  and  treat- 
ment neglects  to  show  wherein  this  knowledge  is  applicable?  This  is 
largely  a  matter  of  comparison.  "We  know  that  in  foreign  countries  the 
clinical  teacher  is  usually  well  prepared  to  use  the  results  of  science. 
In  our  own  country,  outside  some  anatomy,  normal  and  pathological, 
this  statement  can  not  be  made.  Our  best  clinicians  heretofore  have 
been  lacking  in  acquaintance  with  the  facts  and  methods  of  the  under- 
lying experimental  sciences.  This,  however,  is  a  defect  which  time  no 
doubt  will  remedy.  The  newer  appointments  to  these  chairs  will  be 
made  from  a  group  of  men  who  have  enjoyed  the  benefits  of  a  better 
scientific  preparation.  It  would,  however,  be  a  real  advance  if  we  should 
adopt  what  seems  to  be  a  practise  in  other  countries,  namely,  to  require 
those  who  expect  to  take  positions  upon  the  medical  or  surgical  staffs 
to  serve  a  preliminary  year  or  two  in  a  scientific  laboratory,  engaged 
upon  research  not  too  immediately  practical  in  character.  The  sug- 
gestion made  by  Dr.  Bevan  that  the  positions  upon  the  clinical  staff 
might  be  filled  by  men  who  had  served  as  instructors  in  anatomy, 


TEE    MEDICAL    SCHOOL  205 

physiology  or  pathology  is  most  excellent.     If  this  procedure  became 
customary,  if  the  professor  of  medicine,  for  example,  selected  his  assist- 
ants from  the  teaching  staff  of  the  departments  of  physiology,  physio- 
logical chemistry  and  pathology,  we  should  have  an  arrangement  which,  . 
on  the  one  hand,  would  supply  the  clinical  departments  with  well- 
trained  men,  capable  of  undertaking  independent  investigations,  and, 
on  the  other  hand,  would  probably  direct  toward  the  laboratory  sub- 
jects an  abundant  supply  of  young  medical  graduates,  whereas  under 
present  conditions  it  is  frequently  necessary  to  go  outside  medicine  in 
filling  such  positions.    Third,  What  shall  be  the  character  of  the  duties 
and  qualifications  expected  from  those  who  have  the  chief  direction  of 
the  work  in  the  clinical  departments?    It  is  an  interesting  and  some- 
what surprising  fact  that  in  this  part  of  our  system  of  medical  educa- 
tion no  change  of  importance  has  been  made  in  the  methods  of  teach- 
ing during  the  last  few  decades.     So  far  as  the  student  himself  is  con- 
cerned no  fundamental  change  in  opportunities  is  required.     Clinical 
instruction  from  the  students'  standpoint  always  had  the  great  merit 
that  it  employs  what  we  may  call  the  laboratory  method,  as  opposed  to 
the  method  of  learning  from  books.     The  student  is  brought  face  to 
face  with  experiments  made  by  nature  and  he  is  given  an  opportunity 
to  learn  from  personal  experience  rather  than  from  the  experience  of 
others.    In  our  modern  schools  his  opportunities  of  this  kind  have  been 
greatly  increased  and  to  this  extent  his  instruction  has  been  improved 
in  his  clinical  years  along  the  same  line  as  in  his  preparatory  years. 
But  has  there  been  a  development  in  the  methods  of  teaching  in  these 
clinical  years  corresponding  to  that  which  has  taken  place  in  the  labora- 
tory subjects  ?    What  we  find  is  that  the  backbone  of  the  instruction  in 
the  clinical  branches  consists  now,  as  formerly,  of  exercises  in  the 
clinics  and  operating  rooms  of  the  hospital  and  the  dispensary,  and 
these  exercises  are  conducted  by  practitioners  of  medicine  who  devote 
a  little  time  to  their  duties  as  teachers,  but  give  most  of  their  time  and 
energy  to  their  private  interests.    As  long  as  our  medical  schools  were 
private  corporations  founded  partly  for  the  public  good,  but  partly  also 
for  the  personal  advancement  of  the  members  of  the  corporation,  this 
division  of  time  was  natural  and  permissible.    But  our  best  schools  are 
no  longer  private  enterprises;  they  constitute  a  part  of  a  university 
whose  functions  are  solely  to  advance  the  public  good  and  not  in  any 
sense  to  exploit  private  interests.     As  has  been  well  said  by  one  who 


206  MEDICAL   EESEABCH   AND   EDUCATION 

speaks  with  great  authority,  the  university  discharges  its  direct  duties 
to  the  public  in  two  general  ways,  by  teaching  and  by  investigating;  by 
providing  systematic  instruction  in  all  forms  of  that  knowledge  which 
has  been  accumulating  from  the  beginning  of  our  race,  and  by  promoting 
all  good  methods  for  increasing  knowledge.  These  duties  are  performed 
through  her  teachers.  She  therefore  selects  her  professors  for  their 
ability  to  teach  and  to  investigate,  and  to  insure  that  these  functions  are 
performed  in  the  best  possible  way  they  are  required  to  devote  them- 
selves entirely  to  her  service.  In  this  respect,  as  we  know,  the  professors 
in  the  clinical  branches,  and  possibly  also  the  professors  in  some  of  the 
other  professional  schools,  are  on  a  different  plane  from  the  university 
professor  proper.  It  seems  to  me  a  perfectly  proper  question  to  ask 
whether  this  distinction  is  a  necessary  and  advantageous  one.  Does 
it  constitute  an  inherent  characteristic  of  professional  instruction? 
This  is  a  somewhat  delicate  and  complex  question  which  should  be 
discussed  not  simply  from  the  standpoint  of  the  ideal,  but  also  with 
reference  to  what  is  really  feasible  under  conditions  as  they  exist. 
Time  does  not  permit  such  a  discussion  and  I  must  limit  myself  to 
a  brief  statement  of  what  seem  to  me  to  be  the  tendencies  now  devel- 
oping. One  curious,  if  not  important,  phase  I  may  note  in  passing, 
namely  the  practise  that  seems  to  be  growing  of  paying  the  clinical 
professor  the  full  salary  given  to  the  other  professors  in  the  uni- 
versity. The  professor  in  the  clinical  subjects  is  designated  as  a  pro- 
fessor in  the  university,  and  although  he  is  permitted  to  engage  in  a 
lucrative  private  business  he  is  given  a  salary  as  large  as  that  paid  to  the 
usual  professor  who  devotes  his  entire  time  to  his  university  duties. 
There  is  a  manifest  inequity  in  this  practise,  and  it  produces  a  distinct 
feeling  of  discontent  among  the  teachers.  It  would  seem  to  me  that  the 
university  ought  not  to  submit  to  this  condition,  unless  it  is  actually 
forced  to  do  so  to  obtain  the  men  that  it  wants.  As  a  matter  of  fact,  the 
indirect  benefits  attached  to  these  positions  in  a  good  university  school 
are  so  great  that  I  believe  there  would  never  be  difficulty  in  obtaining 
the  best  men  to  fill  them  whether  they  carried  salaries  or  not.  But  if 
a  salary  is  attached  it  should  certainly  not  be  so  large,  under  present 
conditions,  as  that  paid  to  other  university  professors,  otherwise  the 
university  deliberately  places  a  premium  on  the  teaching  done  by  the 
clinical  instructors  which  tends  to  discredit  the  work  of  the  other 
teachers.     But  this  is  a  more  or  less  incidental  matter.     The  really 


THE    MEDICAL    SCHOOL  207 

important  standpoint  from  which  to  view  the  subject  is  what  are  the 
means  by  which  the  university,  through  its  medical  department,  can 
discharge  most  efficiently  its  obligations  to  the  community.  It  wants 
to  send  out  practitioners  of  medicine  qualified  in  the  best  possible  way 
to  treat  the  sick,  it  wants  to  do  its  part  in  throwing  additional  light 
upon  the  causes  and  treatment  of  disease.  Now  the  first  of  these  func- 
tions is  not  so  very  difficult  of  performance.  Under  conditions  as  they 
are  teachers  of  medicine  and  surgery  can  be  obtained  who  will  give  to 
students  the  best  methods  of  diagnosis  and  treatment,  and  so  far  as  the 
limited  time  permits  will  send  them  out  into  the  world  prepared  to 
develop  into  competent  practitioners  of  medicine.  There  can  be  no 
doubt,  however,  that  this  function  would  be  performed  more  satis- 
factorily from  the  standpoint  of  the  school  if  an  arrangement  could  be 
made  whereby  the  professors  gave  more  time  to  the  work  of  instruction. 
The  provisions  made  for  the  advancement  of  knowledge  by  investi- 
gation are  not  so  satisfactory  as  they  should  be.  Whatever  may  be  the 
position  of  a  proprietary  school  in  this  particular,  the  university  school 
surely  can  not  be  satisfied  with  playing  the  part  of  a  mere  reflector  of 
knowledge.  The  spirit  of  investigation  is  wide-spread  in  medicine  at 
the  present  day.  We  have  the  highest  kinds  of  hope  that  the  methods 
of  science  may  be  applied  with  success  to  the  study  of  diseases  of  all 
kinds.  There  has  been  an  extraordinary  increase  in  our  knowledge  of 
infectious  diseases,  and  resulting  therefrom  a  really  wonderful  improve- 
ment in  our  control  of  the  conditions  threatening  public  and  private 
health.  All  this  we  owe  directly  to  the  use  of  the  laboratory  method  of 
investigation.  A  similar  victory  may  be  gained  over  the  numerous  con- 
stitutional and  nutritional  diseases  whose  causes  are  at  present  hidden 
in  the  secrets  of  the  body  metabolism,  but  to  accomplish  this  desirable 
end,  or  at  least  to  accelerate  its  accomplishment,  we  must  organize  more 
satisfactorily  our  means  of  investigation.  Shall  we  limit  our  investiga- 
tions to  the  laboratories  of  the  medical  sciences  and  to  special  institutes, 
or  shall  we  extend  them  into  the  clinical  branches  ?  It  is  almost  useless 
to  put  such  a  question.  Investigation  by  experimental  methods  has 
spread  into  the  clinical  departments,  and  a  great  increase  in  the  develop- 
ment of  this  phase  of  research  activity  may  be  regarded  as  inevitable. 
The  point  that  has  been  raised  and  which  I  should  like  to  emphasize  is 
that  our  present  system  is  not  well  adapted  to  promote  this  kind  of  work. 
Our  custom  is  to  appoint  as  heads  of  these  departments  men  who  are 


208  MEDICAL   BESEABCH   AND    EDUCATION 

engaged  in  the  practise  of  medicine,  and  it  is  perfectly  evident  that  if 
these  men  give  themselves  unreservedly  to  the  demands  of  practise  their 
efficiency  as  teachers  and  investigators  will  be  seriously  impaired,  indeed, 
in  the  latter  particular,  will  probably  be  destroyed  altogether.  To 
attain  the  combination  of  those  qualities  which  are  most  desirable  from 
the  view-point  of  the  university  one  of  two  changes  should  be  made. 
Either  there  should  be  a  definite  limitation  placed  on  the  time  given  to 
outside  practise,  so  that  opportunity  of  a  known  extent  may  remain  for 
teaching  and  research,  or  these  positions  should  be  placed  squarely  on 
a  university  basis,  the  practise  of  the  incumbents  being  limited  to  the 
hospital  and  dispensary  and  the  laboratories  attached  to  them.  The 
two  propositions  bear  to  each  other  somewhat  the  relation  of  a  half  loaf 
to  a  whole  loaf.  Neither  of  these  principles  is  in  force  to-day,  so  far 
as  I  know,  in  any  of  our  better  schools.  Investigations  that  bear  directly 
on  the  problems  of  practical  medicine  are  carried  on  in  the  laboratories 
of  the  medical  sciences,  in  the  special  institutes,  and  by  the  younger 
men  in  the  clinical  departments  who  are  preparing  themselves  for 
higher  positions.  We  possess  also  a  certain  small  number  of  professors 
of  medicine  and  surgery  who,  in  spite  of  abundant  opportunities  offered 
to  enlarge  their  incomes,  are  so  deeply  interested  in  the  work  of  investi- 
gation that  they  voluntarily  limit  their  outside  practise  and  devote  a 
considerable  portion  of  their  time  and  energy  to  genuine  research. 
These  are  noble  spirits,  for  they  make  a  real  sacrifice  for  the  sake  of  a 
worthy  principle.  Medicine  owes  much  to  them  not  only  for  results 
actually  obtained,  but  also  for  their  example  and  influence  which 
permeate  the  whole  department  with  which  they  are  connected,  and 
affect  favorably  to  some  extent  every  student  brought  into  contact 
with  them.  But  the  number  of  such  men  is  very  small,  for  I  would  not 
add  to  this  honor  list  those  whose  names  appear  sometimes  in  our  liter- 
ature as  contributors,  but  who  are  in  reality  patrons  of  research  rather 
than  actual  workers.  The  position  of  our  clinical  professors  in  relation 
to  their  duties  toward  the  school,  on  the  one  hand,  and  their  oppor- 
tunities for  increasing  their  private  practise,  on  the  other,  is  so  similar 
to  that  which  formerly  existed  in  the  departments  of  the  medical 
sciences  that  one  naturally  assumes  a  similar  outcome.  The  practi- 
tioner was  displaced  from  the  chairs  of  anatomy,  physiology  and 
pathology,  because  the  scientific  knowledge  and  laboratory  technique 
had  become  so  specialized  that  it  was  impossible  for  the  man  in  practise 


THE    MEDICAL    SCHOOL  209 

to  do  the  professorial  work  with  honor  and  success.  The  principle  of 
competition  between  the  schools  soon  determined  which  kind  of  pro- 
fessor was  most  needed.  In  the  same  way  precisely  science  and  labo- 
ratory technique  and  the  spirit  of  investigation  are  pushing  hard  into 
the  clinical  branches.  The  professor  of  medicine  who  gives  himself  to 
outside  practise,  and  at  the  same  time  attempts  to  keep  up  with  the 
scientific  development  of  his  subject  and  to  make  and  direct  the  inves- 
tigations which  his  position  in  a  good  school  demands  is  putting  him- 
self under  a  great  strain  at  present,  and  the  indications  are  that  soon 
this  strain  will  become  too  great.  Specialists  will  be  demanded  for  the 
heads  of  our  practical  branches  as  they  are  now  for  our  theoretical 
branches.  It  seems  quite  possible  that  here  again  the  principle  of 
competition  will  be  the  decisive  factor.  The  university  school  which 
shall  first  establish  departments  on  this  basis  may,  and  in  my  opinion 
will,  secure  both  reputation  and  students  as  compared  with  schools 
organized  on  the  present  system.  Whether  a  professor  of  medicine, 
surgery,  obstetrics,  etc.,  whose  practise  upon  patients  is  limited  to  the 
hospital  and  dispensary  will  be  as  well  qualified  as  the  man  with  an 
extensive  outside  practise  to  teach  his  students  medical  art  as  well  as 
medical  science,  and  to  attain  the  proper  influence  among  his  brother 
physicians,  are  questions  that  have  been  somewhat  discussed,  but  the 
only  way  to  find  out  the  correct  answers  is  to  try  the  experiment.  All 
the  theoretical  reasons  favor  such  a  change.  The  practise  of  the  hos- 
pital is  much  more  rigorous  than  private  practise  from  the  standpoint 
of  the  acquisition  of  the  methods  of  diagnosis  and  treatment.  I  fancy 
that  any  physician  will  admit  that  experience  and  real  knowledge  accu- 
mulate at  a  rapid  rate  in  the  hospital  as  compared  with  the  results  of 
the  looser  discipline  of  outside  practise.  A  man  whose  diagnoses  are 
based  upon  the  most  complete  examinations  possible  and  whose  errors 
are  continually  subject  to  the  salutary  correctives  of  autopsy  and 
pathological  demonstration  is  likely  to  make  a  very  exact  and  practical 
teacher.  As  regards  the  matter  of  the  relation  of  these  men  to  the 
medical  public  there  can  be  no  room  for  a  difference  of  opinion.  It  is 
they  who  would  have  the  golden  opportunity  to  acquire  precise  knowl- 
edge, to  keep  thoroughly  abreast  of  the  latest  and  best  in  the  medical 
world.  It  is  they  who  in  medical  societies  and  medical  journals  would 
be  best  qualified  to  speak  with  full  knowledge,  and  in  professional 
circles  knowledge  gives  authority,  whatever  may  be  the  case  with  the 
15 


210  MEDICAL   BE  SEARCH   AND   EDUCATION 

public  at  large.  A  practical  difficulty  in  making  such  a  change  in  the 
character  of  the  appointments  to  the  clinical  chairs  is  the  doubt  whether 
properly  prepared  men  would  be  willing  to  surrender  the  rewards  and 
popular  appreciation  that  are  attached  to  the  career  of  a  successful 
physician.  This  is  again  the  kind  of  question  that  discussion  does  not 
throw  much  light  upon.  When  we  meet  with  difficulties  of  this  kind  in 
laboratory  work  we  put  the  matter  to  the  test  of  experiment  and  thereby 
settle  the  dispute.  Our  country  is  in  a  peculiarly  favorable  position  to 
make  such  an  experiment.  Our  system  of  medical  education  has  hereto- 
fore simply  developed  along  lines  laid  down  by  the  experience  of  foreign 
countries;  perhaps  in  the  direction  suggested  above  we  may  have  an 
opportunity  to  take  the  lead  instead  of  trailing  along  in  the  rear,  I 
have  had  occasions  to  talk  with  a  number  of  young  clinicians  on  this 
topic  and  I  have  arrived  at  the  conviction  that  many  of  them  would 
eagerly  accept  an  offer  which,  while  assuring  them  a  modest  but  suffi- 
cient competence,  would  also  open  to  them  a  career  so  promising  in 
influence,  reputation  and  possibilities  for  doing  the  highest  good  to 
mankind. 


LIBERTY  IN"  MEDICAL   EDUCATION^ 

By  Franklin  P.  Mall,  M.D.,  D.Sc,  LL.D., 
Pbofessob  of  Anatomy,  The  Johns  Hopkins  Univeesity 

A  QUARTER  of  a  centurj  ago  the  medical  schools  of  this  country 
gave  an  annual  course  of  lectures  which  was  attended  by  all  students 
and  was  repeated  each  year.  For  this  privilege  students  paid  a  single 
fee,  for  which  they  heard  much,  saw  little,  and  did  nothing.  There 
were  no  requirements  for  admission  and  very  few  for  graduation.  At 
the  end  of  the  session  the  trustee-members  of  the  faculty  divided  the 
profits  among  themselves.  Since  that  time,  however,  great  strides  have 
been  made  in  the  direction  of  improvement,  stimulated  mainly  by  other 
educational  movements  in  the  country.  The  quality  of  the  professor 
has  been  improved,  a  graded  course  of  instruction  has  been  introduced, 
and  requirements  for  admission  have  been  established.  These  improve- 
ments have  been  supported  chiefly  by  the  educated  people,  on  the  one 
hand,  and  by  the  medical  profession,  on  the  other,  by  causing  state  laws 
to  be  introduced  regulating  the  practise  of  medicine.  Schools  of  medi- 
cine have  thus  grown  from  one  course  of  lectures,  extending  over 
five  months,  to  four  graded  courses  of  nine  months  each.  The 
requirements  for  admission  have  been  increased  from  nil  to  a  liberal 
education  as  expressed  by  a  college  degree.  The  quality  of  the  professor 
has  also  kept  pace  with  the  increased  requirements  of  the  medical  school. 

There  are  at  present  in  the  United  States  forty-eight  medical  col- 
leges having  courses  extending  over  three  years,  and  seventy  colleges 
having  courses  extending  over  four  years.  Of  the  latter  group,  fourteen 
have  sessions  of  eight  months  each  and  eight  have  sessions  of  nine 
months.^  This  group  of  eight  schools  has  in  general  increased  the  re- 
quirements for  admission  to  a  high-school  education,  while  one  of  them 
demands  a  college  education  with  a  college  degree.  Two  of  them  have 
announced  that  in  the  near  future  the  requirements  for  admission  shall 
be  increased  beyond  the  present  standard.    On  account  of  the  lead  thus 

^Published  in  The  Philadelphia  Medical  Journal,  April  1,  1899. 
'Eeport  of  the  Commission  of  Education,  1896- '97,  Vol.  2,  p.  1792. 

211 


212  MEDICAL   SESEABCE   AND    EDUCATION 

taken  by  these  institutions,  as  well  as  for  their  general  good  standing,  I 
shall  term  them  medical  schools  of  the  first  order. 

In  order  to  raise  the  standard  of  the  medical  schools  of  twenty-five 
years  ago  to  that  of  the  schools  of  the  first  order  as  they  exist  at  present, 
it  has  been  necessary  to  pass  through  the  stages  of  graded  courses,  for 
in  so  doing  not  only  could  the  value  of  graded  and  progressive  courses 
be  demonstrated  to  all  who  took  them,  but  at  the  same  time  unworthy 
students  could  be  eliminated.  Experience  teaches  that  the  student  who 
has  been  well  trained  in  the  fundamental  departments  of  medicine 
demands  a  more  careful  training  in  subsequent  studies;  accordingly  it 
follows  that  if  we  wish  to  attain  to  higher  standards  in  the  practical 
branches  the  teachers  in  the  fundamental  departments  especially  must 
be  first  improved.  An  effort  in  this  direction  is  what  we  are  witnessing 
at  present  all  over  the  country.  The  institutions  are  demanding  better 
courses  in  anatomy,  physiology  and  pathology,  while  the  students, 
propter  lioc,  are  demanding  better  medicine  and  surgery.  If  I  have 
calculated  correctly  the  forces  at  work  the  outcome  of  the  movement  will 
be  that  in  less  than  another  quarter  of  a  century  the  standard  of  the 
schools  which  remain  will  be  as  high  as  that  of  the  schools  of  the  first 
order  is  at  present.  Such  a  result,  of  course,  absolutely  depends  upon 
the  schools  of  the  first  order  retaining  the  lead,  and  on  their  gaining  in 
addition  stronger  support  from  improved  state  examinations. 

The  immediate  effect  of  the  introduction  of  the  graded  course  of  three 
years,  in  1880,  was  a  marked  falling  off  of  the  total  number  of  medical 
students,  and  this  decrease  continued  until  1887.^  Since  then  the  num- 
ber of  students  has  gradually  increased  until  at  the  present  time  there 
are  more  than  twice  as  many  students  as  there  were  ten  years  ago. 
Graduates  of  recent  years  know  only  too  well  the  difficulties  in  gaining 
a  livelihood,  and  our  present  students,  with  greatly  increased  opposition 
from  state  laws,  the  multiplication  of  dispensaries,  and  the  distribution 
of  trained  nurses,  have  also  a  very  poor  outlook.  The  improvement  in 
the  quality  of  the  student  and  of  his  education  will  not  necessarily 
guarantee  a  practise  when  there  are  already  too  many  physicians. 

The  schools  of  the  first  order  have  before  them  a  responsibility  far 
greater  than  increasing  the  number  of  their  students  and  of  graduates. 
In  order  to  keep  in  the  lead  they  must  at  once  improve  the  quality  of 
their  teaching-force  and  also  give  better  facilities  to  select  students.    At 

^Eeport  of  the  Commission  of  Education,  1896- '97,  Vol.  2,  p.  1190. 


LIBEBTT    IN    MEDICAL    EDUCATION  213 

the  University  of  Michigan  and  at  the  Johns  Hopkins  University  the 
authorities  are  in  no  way  hampered  in  the  selection  of  their  professors, 
and  nearly  all  the  latter  are  chosen  from  distant  universities.  The  other 
medical  schools  of  the  first  order  are  rapidly  adopting  the  same  method. 
This  is  a  most  hopeful  sign,  for  nothing  is  more  detrimental  to  educa- 
tional institutions  than  the  "inbreeding"  of  professors.  To  increase 
the  length  of  the  medical  course  beyond  four  years  does  not  seem  to  me  to 
be  advisable.  The  requirements  for  admission  to  the  Johns  Hopkins 
Medical  School  are  sufficiently  high,*  and  the  other  schools  of  the  first 
order  promise  to  approach  this  requirement. 

In  the  old  medical  course  of  one  session,  the  student  at  best  gained 
some  idea  of  medical  lore,  and,  in  case  he  was  deficient  in  this,  he  took 
the  course  again,  thus  making  a  two  years'  course  of  it.  "When  the 
three-year  graded  course  was  introduced  the  second  year  was  the  first 
year  taken  over  again,  with  a  special  third-year  course  added.  In  this 
way  the  student  heard  each  course  of  lectures  twice  in  order  to  make  him 
retain  the  facts.  But  from  examination  it  was  found  that  the  student 
remembered  but  little  of  what  he  had  heard,  and  a  new  force  was  intro- 
duced to  aid  him  in  the  memorizing  process.  Young  instructors  or  in- 
dividuals not  usually  connected  with  the  institution  extracted  the 
essence  of  the  course  of  lectures  and  drilled  this  into  the  classes.  Thus 
arose  the  quiz  method  of  instruction,  so  common  in  many  medical 
schools.  This  helped  the  student  to  remember  a  sufficient  amount  to 
pass  the  examination,  and  all  appeared  satisfactory,  for  no  one  asked 
whether  or  not  the  student  had  actually  gained  knowledge  and  skill 
enough  to  practise  medicine  and  surgery.  Even  to-day  it  is  the  recita- 
tion upon  the  lectures,  laboratory  work,  or  an  assigned  subject  from  a 
text-book  that  is  employed  as  a  test  of  a  man's  capacity.  In  all  cases  it  is 
"  learn  the  lesson  we  have  set  for  you,  recite  well,  then  pass  the  examina- 
tion, and  after  you  have  satisfied  each  instructor  in  this  way,  you  are  a 
Doctor  of  Medicine."  In  my  opinion  no  method  of  training  could  be 
worse  for  a  good  student,  while  it  puts  a  premium  upon  the  mediocre 
candidate. 

*A  degree  in  arts  or  science  from  an  approved  college,  at  least  a  year's 
laboratory  training  in  physics,  chemistry  and  biology,  and  a  reading  knowledge 
of  French  and  German.  After  June^  1901,  candidates  for  admission  to  Har- 
vard Medical  School  must  present  a  degree  in  arts,  literature,  philosophy,  science 
or  medicine,  etc. — Announcement  of  the  Medical  School  of  Harvard  University, 
1898- '99,  p.  12. 


214  MEDICAL  BESEABCE  AND   EDUCATION 

If  we  ask  the  question — how  may  we  make  it  possible  that  the 
individual  may  assert  himself,  and  how  can  we  give  the  student  a  chance 
to  test  the  use  of  the  knowledge  he  may  possess  ? — ^we  need  not  seek  far 
for  the  reply.  We  have  only  to  inquire  into  the  methods  in  vogue  in 
the  leading  medical  schools  of  Europe,  which  are  in  many  respects 
identical  with  those  of  the  graduate  schools  of  our  own  universities. 
European  medical  schools  and  American  graduate  schools  afford  facili- 
ties in  a  great  variety  of  subjects  for  those  who  may  profit  by  them. 
"When  the  student  has  pursued  enough  courses  (no  two  students  neces- 
sarily having  followed  exactly  the  same  course)  to  enable  him  to  apply 
for  a  degree,  he  is  examined,  and  in  case  he  passes,  the  degree  is  granted 
him.  Adapting  this  more  liberal  method  to  our  own  medical  schools  a 
plan  may  be  formulated  as  follows : 

1.  Entrance  examination.  Followed  by  at  least  two  years'  study  of  the 
fundamental  branches. 

2.  Intermediate  examination.  Followed  by  at  least  two  years'  study  of  the 
practical  branches. 

3.  Final  examination.  The  subject  of  examinations  will  be  referred  to 
further  on  in  the  course  of  my  remarks. 

Throughout  the  course  thus  outlined,  the  greatest  latitude  possible 
should  be  offered  the  student  in  the  arrangement  of  his  studies  selected 
from  (1)  a  required  list,  as  well  as  from  (2)  an  extensive  group  of 
filectives,  as  recently  advocated  by  Bowditch.^ 

We  all  know  that  students  are  very  unequal  in  ability,  as  well  as  in 
capacity  for  work,  and  why  should  they  all  pursue  the  same  course  of 
study?  It  is  certainly  very  injurious  for  students  to  repeat  courses 
with  which  they  are  familiar,  feeling  at  the  time  that  they  do  not  grow 
from  day  to  day.  Furthermore,  it  is  not  beneficial  to  the  true  student 
to  study  with  a  whip  over  him,  and  we  know  only  too  well  that  this 
weapon  is  more  often  used  by  a  poor  instructor  upon  a  good  student  than 

*  Bowditch,  Boston  Medical  and  Surgical  Journal,  December  29,  1898.  At 
present  there  is  an  elective  system  at  Harvard  and  at  the  University  of  Penn- 
sylvania, representing  about  2  per  cent,  of  the  entire  medical  course.  President 
Harper  has  just  introduced  an  elective  system  into  Kush  Medical  College,  repre- 
senting 17  per  cent,  of  the  entire  course.  There  are  elective  courses  at  the  Uni- 
versity of  Michigan,  Columbia  and  Johns  Hopkins,  but  they  do  not  give  credit  to 
the  student  further  than  the  increased  knowledge  he  may  gain  in  taking  them. 
Students  already  overworked  are  not  likely  to  take  electives  without  prolonging 
their  course  of  study,  and  there  is  so  much  disgrace  accompanying  the  prolonga- 
tion of  the  medical  course  under  the  present  arrangements  that  this  alone  debars 
students  from  wilfully  doing  it. 


LIBESTY    IN    MEDICAL    EDUCATION  215 

by  a  good  instructor  upon  a  poor  student.  If  we  had  a  liberal  elective 
system  the  student  would  know  why  he  takes  a  course,  and  under  this 
condition  should  profit  much  more  by  it.  To  profit  most  the  student 
must  gain  a  perspective  of  his  medical  course.  In  my  association  with 
German  medical  students  I  have  witnessed  frequently  the  value  of  this 
point,  emphasized  centuries  ago  by  Quintilian.  While  battling  to 
establish  themselves  in  an  elective  course  of  study  a  certain  number  fail 
and  quietly  withdraw  from  medicine;  the  average  students  continue 
along  the  trodden  path,  while  the  strong  students  become  much  more 
powerful. 

Do  we,  with  our  obligatory  methods,  accomplish  as  much  ?  I  think 
not.  We  cast  out  the  poor  students  and  disgrace  them,  the  mediocre 
continue  along  the  trodden  path,  but  the  best  are  retarded.  We  do  wrong 
when  we  disgrace  the  weak  and  it  is  our  duty  to  develop  the  strong. 
It  is  poor  logic  and  begging  the  question  to  assert  that  the  German 
student  develops  better  under  the  banner  of  liberty  than  the  American 
would.  It  is  not  difficult  to  obtain  overwhelming  authority  in  favor  of 
liberty  in  higher  education;  it  is  only  degrading  to  our  profession  in 
America  to  assert  that  our  students  are  not  worthy  of  it.  As  long  as 
this  continues,  medical  education  in  America,  in  spite  of  the  advance  it 
has  made  during  the  last  twenty-five  years,  will  remain  at  its  present  low 
level  in  the  eyes  of  the  educators  of  .the  world. 

Only  a  few  years  ago  all  students  who  graduated  at  Harvard  College  passed 
through  one  uniform  curriculum.  Every  man  studied  the  same  subjects  in 
the  same  proportions,  without  regard  to  his  natural  bent  or  preference.  The 
individual  student  had  no  choice  of  either  subjects  or  teachers.  This  system  is 
still  the  prevailing  system  among  American  colleges,  and  finds  vigorous  defenders. 
It  has  the  merit  of  simplicity.  So  had  the  school  methods  of  our  grandfathers 
— one  primer,  one  catechism,  one  rod  for  all  children.  On  the  whole,  a  single 
common  course  of  studies,  tolerably  well  selected  to  meet  the  average  needs, 
seems  to  most  Americans  a  very  proper  and  natural  thing,  even  for  grown  men." 

What  is  written  above  has  in  it  the  spirit  of  iconoclasm,  and  it  re- 
mains to  be  shown,  and  I  think  it  can  be  shown,  that  it  is  possible,  in 
fact  necessary,  to  bring  about  a  change  in  the  curriculum,  even  in  the 
schools  of  the  first  order,  to  relieve  their  congested,  illogical,  and  often 
absurd  medical  programs. 

The  following  table  has  been  compiled  from  the  announcements  of 
six  of  the  leading  medical  schools  and  I  give  it  with  considerable  reserva- 

•  Eliot,  Inaugural  Address  as  President  of  Harvard  College,  October,  1869. 


216 


MEDICAL   BESEAECH   AND    EDUCATION 


tion.     Any  one  trying  to  confirm  it  will  appreciate  the  difficulty  in 
determining  the  duration  of  the  various  courses  in  them. 

Table  Showing  the  Number  of  Hours  '  Work  Given  in  the  Various 
Departments  of  Six  of  the  Leading  Medical  Schools 


Anatomy  and  histology 

Physiology 

Physiol,  chemistry  and  pharmacology 

Bacteriology  and  pathology  — 

Other  subjects...  

Medicine 

Surgery 

Gynecology 

Obstetrics 

Dermatology 

Pediatrics  

Nervous  diseases 

Genito-urinary  diseases 

Laryngology 

Ophthalmology 

Other  subjects  

Total 


A 

B 

C 

D 

E 

500 

500 

950 

890 

695 

250 

210 

300 

150 

120 

275 

105 

300 

250 

465 

300 

185 

200 

570 

330 

150 

60 

240 

255 

625 

420 

460 

515 

480 

470 

390 

385 

570 

670 

60 

180 

160 

235 

|260 

200 

180 

220 

280 

30 

120 

40 

100 

100 

15 

90 

40 

80 

90 

30 

100 

120 

15 

30 

65 

120 

110 

15 

120 

40 

100 

120 

100 

300 

40 

100 

105 

90 

330 

75 

30 

90 

3,125 

3,320 

3,515 

4,130 

3,890 

825 
160 
530 
560 
595 
320 
660 

380 

95 

325 
}480 

90 
5,020 


In  glancing  over  the  lines  it  is  seen  that  the  time  devoted  to  any  of 
the  important  subjects  varies  fully  100  per  cent,  in  different  schools. 
In  some  of  the  specialties  it  varies  nearly  1,000  per  cent.  These  facts 
in  themselves  are  overwhelming  evidence  in  favor  of  elective  courses. 
If  the  correct  quantity  and  order  of  the  subjects  are  known,  as  is  so 
frequently  asserted,  why  this  great  fluctuation  in  hours  ?  If  a  student 
of  his  own  accord  takes  325  hours  of  nervous  disease  at  school  F,  that  is 
his  own  affair;  but  why  should  all  students  take  325  hours?  At  school 
A,  on  the  other  hand,  if  he  desires  to  take  but  30  hours,  it  is  again  his 
own  affair,  but  why  should  all  of  them  take  so  little  ?  A  similar  argu- 
ment can  be  applied  to  every  course.  Were  the  elective  system  in  vogue 
a  student  might  arrange  the  studies  of  school  A  like  those  of  any  of  the 
other  schools  given  in  the  table,  or  he  might  have  any  intermediate 
gradation.  But  how  can  this  be  done?  "We  know  that  in  all  of  the 
leading  schools  the  year  is  divided  either  into  two  semesters,  or  into 
three  terms.  Let  us  consider  only  the  institutions  with  two  semesters, 
and  what  applies  to  them  may  apply  equally  well  to  the  others.  Several 
fundamental  principles  will  have  to  be  introduced. 

1.  The  work  in  each  department  must  be  graded. 

2.  No  course  may  extend  over  one  semester. 


LIBEETY    IN    MEDICAL    EDUCATION  217 

3.  The  courses  must  be  concentrated.  Every  course  should  be  given 
at  least  three  hours  a  week.  Individual  course-records  must  be  kept,  as 
is  the  case  in  all  colleges. 

For  the  sake  of  brevity  I  will  designate  a  course  of  three  hours  a  week 
for  one  semester  a  unit,  for  half  that  time  a  half  unit;  three  half-days' 
laboratory  course  for  one  semester  as  two  units,  for  half  that  time  as 
one  unit.  Within  this  time  all  necessary  medical  courses  can  be  given. 
The  main  clinical  courses  may  be  longer,  but  may  be  cut  into  blocks  of 
a  semester  each,  and  this  makes  it  easy  to  bring  them  into  the  scheme. 

The  courses  in  a  department  being  graded,  they  will  have  to  be 
arranged  in  such  a  manner  that  students  knowing  nothing  about  the 
work  of  the  department  may  be  given  introductory  courses  in  it  during 
each  semester.  After  the  introductory  courses  have  been  taken  they 
may  take  then  the  more  advanced  work  of  the  department.  The  out- 
come of  it  all  will  be  that  each  student  will  work  at  a  speed  to  suit  him- 
self, conforming  only  to  the  rules  and  regulations  of  the  department, 
and  being  controlled  in  addition  by  the  examination  system  of  the  uni- 
versity, as  follows.  He  may  not  enter  the  school  as  a  candidate  for 
the  degree  of  M.D.  without  having  passed  the  entrance  examination. 
He  may  not  take  any  of  the  practical  branches  without  having  passed 
without  condition  the  intermediate  examination,  the  time  between  the 
entrance  examination  and  the  intermediate  examination  to  be  fixed  at  a 
minimum  of  four  semesters  or  their  equivalent.  In  case  he  is  condi- 
tioned in  any  course  he  may  be  examined  one  semester  later.  The  same 
rules  may  apply  to  the  time  between  the  intermediate  and  the  final  ex- 
aminations. 

I  have  used  above  as  time  unit  the  semester  or  its  equivalent.  It  is 
noticed  in  the  hours  given  in  the  table  that  the  whole  medical  course  at 
medical  school  A  is  3,000  hours;  at  F,  5,000  hours.  A  total  of  3,000 
hours,  or  750  per  year,  is  full  work  in  the  undergraduate  science  course 
of  our  leading  colleges,  and  may  be  considered  the  standard  for  a 
medical  course.  With  three  hours  a  week  for  one  semester  as  one  unit, 
and  three  half-days'  laboratory  work  one  semester  as  two  units,  a  stu- 
dent taking  six  units  per  semester  would  be  doing  full  work  as  rated  by 
college  standards.  Twelve  units  would  represent  a  year's  work,  and 
twenty-four  units  two  years'  work,  or  the  minimum  requirements  for 
persons  presenting  themselves  for  the  intermediate  examination.  In  a 
more  detailed  form  the  work  of  the  best  schools  can  be  recast  with  the 
above-described  unit  as  basis  in  some  such  manner  as  the  following : 


218  MEDICAL   RESEABCE   AND   EDUCATION 

Table  Showing  the  Medical  Curriculum  Eecast  With  the  Unit  as  Basis 
AND  Obligatory  and  Elective  Courses 
Entrance  Examination 

Obligatory  Elective 

Anatomy   6  units  15 

Physiology    2     "  4 

Physiological  Chemistry  and  Pharmacology  .  3     **  6 

Pathology  and  Bacteriology  4     "  10 

Hygiene  and  Bacteriology    10 

Elective   9  or  more 

24:=  two  years'  work. 

Intermediate  Examination  (Anatomy,  Physiology,  Pharmacology  and 

Pathology) 

Obligatory  Elective 

Medicine    6  units                            15 

Surgery    5     "                                15 

Obstetrics    3     "                                  5 

Gynecology   5 

Dermatology     4 

Pediatrics    4 

Nervous  Diseases 5 

Genito-Urinary   Diseases    4 

Laryngology   4 

Ophthalmology    5 

Medical  Jurisprudence 2 

Psychiatry  v                                  4 

Elective   10  or  more 

24  =  two  years'  work. 

Final  Examination  (Medicine,  Suegery,  Obstetrics,  and 

One  Elective) 

In  the  above  table  I  have  arranged  the  units  in  two  columns,  reduc- 
ing the  obligatory  courses  to  their  minimum  without  excluding  any  of  the 
seven  branches.  Further  cutting  down  might  be  an  improvement,  but 
I  will  not  raise  that  question  at  present.  As  it  stands  in  the  table  60 
per  cent,  of  the  entire  four  years  is  obligatory  and  the  remaining  40  per 
cent,  of  the  work  is  to  be  selected  from  a  large  group  of  elective  courses. 
As  they  stand  in  the  second  column  it  would  require  an  average  student 
eight  or  ten  years  to  take  them  all,  and  the  two  columns  together  repre- 
sent work  which  our  best  schools  can  easily  give  at  the  present  time. 
Much  of  our  whole  trouble  in  teaching  is  that  we  are  trying  to  put  ten 
years'  work  into  four. 

In  case  a  school  measured  the  time  of  a  student  by  the  number  of 
units  he  had  taken,  it  might  be  well  to  credit  him  only  with  six  units 


LIBEETY    IN    MEDICAL    EDUCATION  219 

per  semester  in  order  to  discourage  overwork.  It  would  be  his  privilege 
to  do  as  much  additional  work  as  he  chooses,  but  in  case  he  did  less  than 
six  units  per  semester  he  would  be  credited  for  the  amount  he  had  really 
taken.  The  course-records  might  be  controlled  by  practical  tests  at  the 
end  of  a  laboratory  course  or  by  a  brief  written  examination  at  the  end 
of  a  lecture  course,  it  being  distinctly  understood,  however,  that  these 
examinations  are  only  to  give  credit  for  the  course.  It  might  happen 
that  weak  students,  and  often  strong  students,  would  take  more  than 
twenty-four  units  before  applying  for  the  intermediate  examination. 

The  order  in  taking  the  work  of  the  first  half  of  the  medical  course 
should  not  be  controlled  any  more  than  the  rules  of  any  department 
control  them.  It  might  be  well  for  the  course  in  pathological  histology 
to  be  preceded  by  histology  and  microscopic  anatomy,  but  more  than 
this  is  hardly  necessary.  If  a  student  desired  to  take  the  pathological 
histology  without  having  had  normal  histology  and  the  instructor  did 
not  object,  the  student  would  have  to  take  the  consequences.  I,  myself, 
did  this  as  a  student  in  Heidelberg  and  to  this  day  have  not  regretted  it. 

After  the  intermediate  examination  the  student  would  take  the  neces- 
sary courses  preparatory  to  actual  medical  and  surgical  work,  and  for 
this  purpose  there  is  always  an  abundance  of  instructors  on  hand.  The 
group  question  would  soon  disappear,  for  a  student  might  take  sufficient 
elective  courses  to  save  time  in  reaching  his  goal,  i.  e.,  doing  practical 
work.  Each  student  might  try  a  different  combination  while  working 
out  his  own  salvation  and  developing  his  individuality.  The  weak 
student  would  either  drop  out  or  go  slower,  the  average  would  follow  the 
trodden  path,  the  good  one  would  develop  himself.  A  congested  course 
would  soon  be  duplicated,  the  arrangement  of  the  program  would  be 
extremely  simple,  and  courses  of  no  value  would  soon  die  a  natural 
death.  Demand  and  supply  would  become  the  important  questions  of 
each  institution  and  the  "trust"  method  of  supporting  either  a  poor 
student  or  a  poor  instructor  would  soon  disappear. 

The  great  complaint  of  the  good  student  is  coercion.  Reared  in  a 
free  atmosphere,  accustomed  to  great  liberty  during  his  college  years, 
he  enters  the  medical  school  with  intellectual  slavery  staring  him  in  the 
face.  The  faculty  trust  is  so  powerful  that  if  the  student  asserts  his 
citizenship  and  remains  away  from  a  stupid  course  or  one  useless  to  him- 
self he  may  be  deprived  of  his  degree.  Long  after  he  graduates  he 
awakens  to  see  that  it  is  all  a  sham,  and  this  fact  adds  another  dis- 


220  MEDICAL   EESEABCR   AND   EDUCATION 

grace  to  our  medical  schools.  Let  us  boldly  define  the  work  which  is 
absolutely  necessary  for  each  student  to  do;  give  an  abundance  of  elect- 
ives  from  which  he  must  select  a  certain  amount  and  then  have  a 
rational  system  of  examination. 

The  bugbear  of  examination  is  so  great  that  in  my  opinion  it  would 
be  well  to  separate  it  from  the  course  of  instruction  entirely.  Many 
examinations  are  such  an  utter  farce,  so  bad  and  so  detrimental,  that 
both  physicians  and  many  faculties  have  lost  faith  in  them  entirely. 
ISTo  greater  argument  need  be  given  than  the  fact  that  the  physicians  of 
many  states  will  not  permit  the  members  of  a  teaching  faculty  to  serve 
on  the  state  examining  board,  while  in  some  of  the  medical  schools  it  is 
required  that  the  student  write  his  examination  over  a  secret  number  in 
order  that  the  reader  of  the  paper  does  not  know  who  has  written  it. 
Think  of  it !  Then  to  bring  this  evil  force  into  the  lecture  hall  and  the 
laboratory !  But  some  compromise  is  here  necessary,  for  how  shall  we 
determine  whether  or  not  the  student  has  really  taken  the  course?  In 
Germany  simple  payment  of  a  fee  for  a  course  and  a  perfunctory  signa- 
ture of  the  instructor  give  the  student  credit  for  the  course.  In  Aus- 
tria the  instructor  must  sign  the  student's  book,  to  which  is  attached 
his  photograph  with  a  seal  through  it  at  the  beginning  and  again  at  the 
end  of  the  course.  If  we  had  some  method  a  little  more  rigid  than 
that  in  Austria  it  would  suffice,  for  I  think  that  we  should  "do  away 
with  examinations  as  much  as  possible.     They  produce  mediocrity."'^ 

The  intermediate  and  final  examinations  should  be  true  examina- 
tions to  test  a  student's  knowledge.  At  least  two  weeks  should  be  given 
over  to  the  examination  in  anatomy,  during  which  time  the  student 
should  be  asked  to  make  dissections,  histological  preparations  and  the 
like.  The  examinations  should  not  be  primarily  directed  toward  finding 
out  what  the  student  Tcnows;  rather  toward  learning  what  he  can  do  with 
the  knowledge  he  possesses.  They  should  always  be  public  in  order  to 
protect  both  the  student  and  the  examiner.  The  great  length  of  time 
given  over  to  the  examination  should  remove  most  of  the  embarrassment 
of  the  student,  which  accompanies  the  briefer  and  crushing  Ph.D. 
examination.  In  addition  to  the  examination  the  credentials  of  the 
student  should  always  be  taken  into  consideration,  for  it  is  through  them 
that  we  learn  what  the  student  has  actually  done,  as  well  as  much  con- 
cerning the  general  character  of  the  man.  With  a  liberal  s^'^stem  of 
electives  no  two  sets  of  credentials  would  be  the  same. 

"Paulson,  Rein's  Encyklop.  Handbuch  d.  Padagogik. 


LIBEBTT    IN    MEDICAL    EDUCATION  221 

The  value  of  liberty  in  education  has  been  pointed  out  again  and 
again  from  the  student's  standpoint/  but  the  benefit  it  renders  an  in- 
stitution should  not  be  forgotten.  Liberty  to  the  student  should  not 
mean  license  to  him,  but  rather  liberty  also  to  the  instructor.  This 
question  stirs  our  medical  schools  to  their  very  foundation.  At  present 
our  medical  institutions  are  properly  called  schools  and  none  of  them 
can  claim  true  relationship  to  the  university.  A  medical  department  of 
a  university  must  consist  of  a  group  of  independent  departments,  each 
a  complete  organization  in  itself,  existing  primarily  as  a  conservator  of 
the  branch  it  represents.  Teaching  beginners  may  become  its  main 
work,  but  should  never  be  its  chief  ideal.  These  departments  must  be 
related  to  the  university  as  a  whole,  as  is  the  department  of  chemistry  or 
of  history,  the  former  being  bound  together,  however,  through  the 
medical  faculty  as  the  latter  are  through  the  philosophical.  At  present 
this  ideal  is  reached  by  a  very  few  departments  scattered  throughout  the 
country.  The  rest  are  better  likened  to  the  departments  of  chemistry 
and  history  of  ordinary  colleges  rather  than  universities,  for  they  have 
ideals  of  teaching  in  common  with  the  former.  Their  organization, 
their  desire  to  teach  and  to  examine,  and  the  graded  course  of  instruc- 
tion, make  the  better  medical  schools  similar  to  the  average  colleges. 
Some  of  the  colleges  are  more  liberal  and  more  nearly  related  to  the 
university  than  are  the  best  medical  schools. 

We  must  remember  that  departments  are  unable  to  grow  and  perform 
their  duty  best  when  their  ideals  are  no  higher  than  those  of  compulsory 
education.  In  their  halls  must  live  in  the  fullest  degree  the  various 
sciences  represented  by  them.  There  the  science  must  also  grow,  and  this 
is  possible  only  with  the  banner  of  liberty  over  them,  which  would 
be  most  becoming  in  this  country.  We  must  always  remember 
that  it  is  with  this  banner  over  the  German  university  that  the  greatest 
progress  has  been  made ;  that  embryology  was  there  born  simultaneously 
in  the  departments  of  anatomy,  physiology  and  zoology;  that  histology 
appeared  at  the  same  time  in  the  departments  of  anatomy,  physiology 
and  pathology;  and  that  the  greatest  victory  of  modern  medicine, 
bacteriology,  is  also  to  be  credited  to  three  departments — pathology, 
hygiene  and  botany. 

We  are  now  on  the  verge  of  a  new  development  in  medical  progress 
and  education  in  which  the  strongest  support  is  demanded  from  all 

*  See,  for  instance,  Helmholtz,  * '  Akademische  Freiheit, ' '  Berlin,  1878. 


222  MEDICAL  BESEABCH  AND   EDUCATION 

sides.  We  need  capable  men  to  lead,  liberty  in  medical  education  to 
strengthen  them  and  to  develop  their  disciples  and  their  successors; 
endowments  sufficiently  large  to  raise  the  professors  above  the  level  of 
schoolmasters  and  to  make  the  departments  they  represent,  in  reality 
departments  of  a  university. 


MEDICINE  AND  THE  UNIVEESITIES  ^ 

By  Lewellys  F.  Barker,  M.B. 

I  WISH  to  spend  the  time  you  have  courteously  allotted  to  me 
to-night  in  making  a  plea  for  the  better  organization  and  endowment  of 
the  medical  departments  of  universities.  If  you  will  permit  me  to  refer 
in  a  few  words  to  the  character  of  the  medical  schools  of  the  past  and  to 
outline  to  you  some  of  the  features  of  the  medical  schools  of  the 
present,  I  shall  be  the  better  able  to  make  clear  to  you  my  opinion  re- 
garding some  of  the  needs  of  the  medical  school  of  the  future. 

The  Passing  op  the  Proprietary  Medical  School 
The  majority  of  the  medical  schools  in  America  have  developed  as 
proprietary  medical  schools.  Usually  a  group  of  medical  men,  center- 
ing in  one  strong  personality,  formed  a  combination  with  two  objects 
in  view:  (1)  the  education  of  young  men  in  the  medical  art,  (2)  self- 
improvement  and  the  advancement  of  their  own  standing  in  the  pro- 
fession and  with  the  public.  The  course  of  instruction,  brief  at  first, 
was  first  extended  to  two  years,  and  then  to  three.  It  is  now  in  most 
schools  four  years.  The  graded  course  was  a  relatively  late  feature. 
For  many  years  only  one  course  of  lectures  was  given  in  the  school. 
This  course  was  repeated  each  year,  so  that  if  a  student  who  attended 
all  the  lectures  in  his  first  year,  came  back  for  a  second  or  a  third  year, 
he  listened  to  the  same  lectures  over  again.  The  introduction  of  the 
graded  course  by  the  Chicago  Medical  College  (now  the  Medical  De- 
partment of  the  Northwestern  University)  was  therefore  a  distinct  step 
forward.  The  division  of  labor  among  the  instructors  became  more 
marked,  and  the  corps  of  instructors  was  correspondingly  increased. 
The  necessity,  on  the  part  of  the  student,  for  a  grounding  in  subjects 
like  anatomy  and  physiology,  previous  to  clinical  work,  became  apparent. 
Chemistry,  histology,  materia  medica  and  pathology  were  subsequently 
added  to  the  preliminary  training,  though  the  latter  subject  was  taught 
for  a  long  time  chiefly  in  connection  with  the  clinical  work. 

*An  address  delivered  at  the  meeting  of  the  Western  Alumni  of  Johns 
Hopkins  University,  held  at  Chicago,  February  28,  1902.  Published  in  American 
Medicine,  July  26,  1902. 

223 


224  MEDICAL  BESEABCE  AND   EDUCATION 

There  were  no  requirements  of  preliminary  education  for  the  stu- 
dents— or,  if  any,  merely  nominal  ones.  Many  of  the  proprietary 
schools,  whose  whole  income  was  derived  from  the  fees  of  students,  were 
able  to  pay  all  their  expenses  and  to  have  besides  a  handsome  surplus 
at  the  end  of  each  year  for  division  among  the  members  of  the  staff. 
And  aside  from  the  profits  of  the  school  itself,  official  connection  with 
the  staff  of  a  medical  school  came  to  be  of  distinct  financial  value  to  the 
practising  physician  or  surgeon.  The  public,  naturally,  employed  prac- 
titioners who  were  teaching  in  the  medical  schools.  Also,  yoimg 
graduates  of  the  medical  school  who  got  into  difficulties  in  their  own 
practise,  usually  called  into  consultation  their  former  professors.  So 
valuable,  indeed,  became  this  connection  that  some  of  the  incorporated 
medical  schools  took  advantage  of  the  opportunity  in  an  interesting 
way.  The  members  of  the  corporation  would  agree  to  admit  a  practi- 
tioner to  the  teaching  staff  on  payment  of  a  certain  sum  of  money. 
The  cost  of  a  professorship  varied,  of  course,  with  the  situation  of  the 
school  and  its  standing  in  the  community.  I  am  informed  that  pro- 
fessorships may  still  be  purchased  in  some  of  our  medical  schools,  and 
that  they  are  valued  at  as  much  as  two  thousand  dollars  per  chair. 
The  demand  for  chairs  in  such  schools  has  been  so  great  at  times  that  a 
corporation  could  choose  the  better  men  among  the  applicants. 

As  long  as  the  teaching  in  the  medical  schools  was  purely  demon- 
strative the  cost  of  medical  education  was  at  a  minimum.  Anatomy 
was  the  first  subject  to  be  taught  other  than  in  a  demonstrative  way. 
For  as  anatomic  material  became  more  plentiful,  students  dissected  for 
themselves.  The  material  was  not,  however,  expensive,  and  the  labora- 
tories were  of  so  crude  a  nature  that  very  little  money  was  expended  on 
the  workshop.  The  clinical  teaching  was  done  in  hospitals  and  out- 
patient clinics — usually  public  institutions — and  cost  the  corporation 
nothing.  Students,  perhaps,  were  required  to  pay  a  hospital  fee.  The 
hospitals  did  not  belong  to  the  medical  schools,  and  it  was  accordingly 
necessary  to  include  in  the  medical  faculty  those  physicians  and  sur- 
geons who  had  been  fortunate  enough  or  clever  enough  to  secure  ap- 
pointments in  the  hospitals  and  dispensaries.  Where  these  clinical 
institutions  were  in  the  hands  of  politicians,  the  best  practitioners  were 
not  always  on  the  staff. 

When  the  microscope  became  an  important  factor  in  medical  educa- 
tion in  Europe,  American  students  who  had  gone  abroad  for  post- 


MEDICINE    AND    THE    UNIVERSITIES  225 

graduate  instruction  came  back  full  of  enthusiasm  for  microscopic 
work,  and  began  instruction  in  the  use  of  the  instrument  in  histology 
and  pathology.  It  was  very  soon  recognized  that  the  medical  school 
must  offer  extensive  courses  in  normal  and  pathologic  histology. 
This  addition  necessitated  more  than  simple  demonstration  of  micro- 
scopic preparations,  although  the  instruction  began  in  this  way.  It  was 
soon  found  that  the  students  must  themselves  do  work  with  the  micro- 
scope, and  this,  since  laboratories  in  which  microscopic  work  could  be 
given  and  the  microscopes  and  their  accessories  were  expensive,  involved 
a  large  increase  in  the  budget.  In  addition,  students  doing  such  work 
require  a  great  deal  of  personal  attention,  much  more  than  the  short 
time  given  by  instructors  under  the  lecture  system.  Very  few  practi- 
tioners had  had  the  opportunity  of  perfecting  themselves  in  microscopic 
teclmic,  and  the  services  of  the  men  qualified  to  teach  it  were  at  a 
premium.  Indeed,  the  demand  became  so  great  that  certain  men  under- 
took especially  to  fit  themselves  for  such  work.  The  schools  which 
offered  the  best  facilities  in  laboratory  work  attracted  the  most  students, 
and  so  competition  arose  among  the  proprietary  schools  to  excel  in  this 
direction.  Pathologic  anatomy  and  histology  now  became  important 
subjects,  and  at  about  the  same  time  experimental  physiology  developed, 
so  that  it,  with  the  other  two,  had  to  be  given  an  important  place  in  the 
curriculum.  "With  the  advent  of  Pasteur's  discoveries  and  Koch's  re- 
searches, bacteriology  sprang  suddenly  into  favor ;  and  laboratories  fitted 
out  with  thermostats,  culture  tubes,  and  oil-immersion  lenses  were 
everywhere  demanded. 

But  this  necessary  laboratory  instruction  in  physiology,  histology, 
pathology  and  bacteriology  made  such  demands  upon  the  students  that 
those  without  previous  experience  in  chemistry,  physics  and  biology 
were  seriously  handicapped.  And  since  the  standard  of  admission  to 
medical  schools  was  very  low,  the  students  rarely  entered  the  medical 
school  with  such  training,  so  that  the  medical  schools  themselves  were 
compelled  to  try  to  teach  at  least  some  of  these  subjects  in  the  first  year 
of  medicine. 

The  proprietary  medical  schools  thus  found  themselves  in  a  dilemma. 
For  the  enormous  cost  which  accompanied  these  changes  in  the  curric- 
ulum not  only  reduced  the  surplus,  but  wiped  it  out  altogether,  and,  by 
those  who  introduced  them,  rapidly  increasing  deficits  had  to  be  faced. 
The  fees  of  students  in  these  schools  were  found  utterly  inadequate  to 

16 


226  MEDICAL   BESEABCE   AND   EDUCATION 

supply  the  money  which  the  rapid  change  in  teaching  made  necessary. 
Some  relief  had  to  be  sought.  Endowment  for  proprietary  medical 
schools  could  scarcely  be  hoped  for.  The  only  relief,  apparently,  lay  in 
a  combination  of  the  medical  school,  or  at  least  a  part  of  it,  with  the 
scientific  departments  of  a  university  which  received  government  aid 
or  had  private  endowment.  And  so,  between  the  proprietary  schools 
and  such  universities,  various  arrangements  were  entered  into.  Some- 
times a  medical  faculty  was  established  in  the  university;  sometimes 
an  affiliation  was  agreed  upon.  In  some  schools  the  chemistry,  physics 
and  biology  were  taught  in  the  university,  all  the  other  subjects  remain- 
ing in  the  medical  school. 

To-day,  however,  it  is  regarded  as  imperative  that  anatomy,  physiol- 
ogy, pathology  and  bacteriology,  physiologic  chemistry  and  pharma- 
cology, be  taught  on  a  university  basis.  For  each  of  these  subjects 
requires  the  service  of  men  who  have  made  it  their  life-work.  The 
kind  of  instruction  which  has  to  be  given  makes  large  demands  upon  the 
teacher's  time;  indeed  a  conscientious  teacher  of  one  of  these  funda- 
mental sciences  in  a  department  of  a  university  sometimes  finds  it 
difficult  to  get  a  sufficient  amount  of  time  to  undertake  research.  Thus 
it  has  gradually  come  to  pass  that  in  the  good  medical  schools  those 
who  teach  the  subjects  mentioned  no  longer  engage  in  the  practise  of 
medicine,  but  devote  all  of  their  time  and  strength  to  the  teaching  and 
investigation  of  the  sciences  which  they  represent. 

The  Pseudo-university  School 

The  consent  of  a  certain  number  of  the  universities  to  undertake 
the  instruction  of  medical  students  in  some  of,  or,  in  some  places,  all 
of  the  sciences  fundamental  to  medicine  having  been  gained,  there 
speedily  ensued  such  an  enormous  improvement  in  medical  instruction  in 
these  institutions  that  the  desirability  of  the  move  became  quickly  and 
widely  recognized,  and  this  not  only  by  the  medical  profession,  but  by 
prospective  students  and  by  the  public  at  large.  The  success  of  the 
schools  combined  or  affiliated  with  the  larger  and  better  managed  uni- 
versities has  been  so  pronounced  that  most  proprietary  schools  having 
no  such  connection  have  tried  everywhere  to  enter  into  some  such 
arrangement.  In  certain  instances  it  can  not  be  denied  that  medical 
schools  have  sought  rather  the  prestige  of  the  connection  than  any 
material  improvement  in  the  courses  of  instruction.    They  are  no  more 


MEDICINE    AND    THE    UNIVEFSITIES  227 

to  blame  perhaps  than  are  the  universities  that  have  been  willing  to 
receive  them  as  their  medical  departments.  In  spite  of  the  fact  that 
medical  educators  are  unanimous  in  the  opinion  that  adequate  medical 
instruction  can  not  possibly  be  given  when  the  fees  of  students  alone  are 
available  as  a  budget,  some  of  the  poorer  universities,  and  occasionally 
some  of  higher  rank,  have  been  willing  to  undertake  the  responsibility 
of  medical  faculties,  provided  they  did  not  cost  them  anything  finan- 
cially, or  only  a  relatively  small  sum.  Such  medical  schools  I  should 
designate  "pseudo-university  schools." 

The  proprietary  school,  however,  did  excellent  work  in  its  day. 
Magnificent  examples  of  self-sacrifice  are  to  be  met  with  in  the  records 
of  the  faculties  of  such  schools.  Especially  when  the  demands  of  ad- 
vancing science  increased  the  cost  of  medical  education  do  we  find  in 
them  notable  instances  of  generosity  and  unselfishness.  When  deficits 
began  to  appear,  members  of  the  faculty,  instead  of  drawing  salaries, 
recognizing  what  the  school  had  done  for  them  in  increasing  their  prac- 
tise and  reputations,  and  having  the  welfare  of  medical  education  at 
heart,  mulcted  their  own  pockets  to  make  the  sheets  balance.  But  now 
the  period  of  usefulness  of  the  proprietary  school  of  medicine  has  gone. 
The  conditions  are  such  that  its  continuance  is  a  menace  rather  than  a 
help  to  the  community.  The  pseudo-university  schools  are  worse  than 
the  proprietary  schools,  for  they  are  proprietary  schools  in  disguise.. 

The  Semi-univeesity  School 

There  is  a  third  class  of  medical  schools  at  the  present  time  repre- 
sented by  six  or  eight  of  the  best  medical  schools  in  the  United  States. 
This  class  I  shall  designate  as  that  of  the  semi-university  school.  By 
this  I  mean  that  the  subjects  of  the  first  two  years  are  taught  in  the 
university,  by  university  professors,  who  do  not  engage  in  the  practise 
of  medicine,  but  who  give  their  whole  time  and  energies  to  the  teaching 
and  investigation  of  the  sciences  which  they  represent.  The  labora- 
tories of  anatomy,  physiology,  pathology,  etc.,  are  installed  in  the  same 
way  as  are  the  laboratories  of  physics,  chemistry,  zoology  and  botany. 
The  professors  and  their  assistants,  running  careers  in  these  depart- 
ments, are  paid  on  the  same  scale  as,  or,  on  account  of  the  difference  in 
ratio  of  supply  and  demand,  a  little  more  liberally  than,  are  the  pro- 
fessors and  assistants  in  the  other  science  laboratories  of  the  university. 

Generous  sums  have  in  the  better  universities  been  provided  for 


228  MEDICAL   BESEABCH   AND   EDUCATION 

laboratory  furnishings  and  apparatus,  models,  books  and  other  kinds 
of  equipment.  The  fees  of  students  are  not  even  adequate  to  defray 
the  annual  running  expenses,  entirely  aside  from  the  cost  of  initial 
installation,  in  the  departments  of  the  first  two  years. 

The  results  of  making  anatomy,  physiology  and  pathology  true 
university  departments  have  been  most  satisfactory.  Students  are  now 
able  to  obtain  a  thorough  scientific  training  in  these  branches  funda- 
mental to  clinical  work.  Formerly  clinicians  complained  that  the 
medical  students  came  to  them  utterly  unprepared  as  regards  the  struc- 
ture and  functions  of  the  normal  body  and  almost  totally  ignorant  of 
the  changes  which  take  place  in  disease.  Now,  students  accustomed  to 
the  well-regulated,  thoroughly  organized,  rigorous  work  of  the  labora- 
tories on  approaching  the  clinical  work  sometimes  complain  of  a  lack 
of  system  in  the  teaching,  of  unsuitable  arrangement  of  studies,  of  im- 
perfect adjustment  between  departments,  of  insufficient  attention  to 
sequence  of  subjects,  of  unwarrantable  waste  of  time.  In  some  institu- 
tions they  may  even  admit  that  an  occasional  clinical  professor  does  not 
appear  to  be  as  familiar  as  he  should  be  with  the  trend  of  modern  work 
in  anatomy,  physiology,  physiologic  chemistry  and  pathology. 

Especially  gratifying  as  a  result  of  the  change  made  by  the  semi- 
university  school  have  been  the  consequences  for  productive  scholarship. 
Instead  of  the  sterility  which  characterizes  the  departments  of  anatomy, 
physiology  and  pathology  when  they  are  manned  by  practitioners,  in  the 
semi-university  schools  they  have  become  beehives  of  industry,  centers 
of  original  investigation,  and  the  last  decennium  has  seen  the  birth  of 
an  American  Journal  of  Experimental  Medicine,  an  American  Journal 
of  Physiology,  an  American  Journal  of  Medical  Research  and  an 
American  Journal  of  Anatomy — four  scientific  journals  in  which  the 
contributions  are  rigidly  limited  to  the  publication  of  the  results  of 
original  research ! 

The  departments  of  the  last  two  years,  whether  nominally  included 
in  the  university  or  not,  are  situated  entirely  differently  in  these  semi- 
university  schools.  All  of  the  men  who  teach  in  these  departments,  or 
at  least  the  majority  of  them,  are  men  who  are  practising  medicine, 
surgery,  obstetrics,  or  some  one  of  the  specialties.  The  schools  provide 
lecture-rooms,  sometimes  an  outdoor  clinic,  and  in  the  better  ones 
clinical  laboratories.  In  some  of  the  schools  a  few  of  the  younger  men, 
especially  in  connection  with  the  clinical  laboratories,  or  as  assistants  to 


MEDICINE    AND    THE    UNIVERSITIES  229 

the  professors,  are  paid  to  give  their  whole  time  to  the  institution,  and 
do  not  engage  in  practise.  The  professors  themselves,  however,  are 
either  not  paid  at  all  or  are  paid  small  sums,  nearly  always  less  than  the 
remuneration  which  pertains  to  a  university  chair,  and  always  too  little 
to  provide  the  professor  with  a  living  income.  These  professors  are 
often  successful  practitioners,  however,  and  make  incomes  varying 
from  $5,000  to  $25,000  per  year,  or  even  more.  The  universities  seldom 
own  hospitals.  Or,  if  they  have  hospitals,  they  are,  as  a  rule,  small  and 
totally  inadequate  to  provide  the  clinical  facilities  necessary  for  the 
number  of  students  taught.  The  professors  in  medicine,  surgery  and 
obstetrics  usually  have  sufficient  personal  influence,  or  the  school  itself 
is  influential  enough,  to  permit  them  to  utilize  for  teaching  purposes  the 
wards  of  various  charity  hospitals.  The  hospitals  thus  utilized  have 
nearly  all  been  built  for  a  specific  purpose,  namely,  to  provide  beds  and 
treatment  for  charity  patients  in  the  cheapest  possible  way.  The 
majority  of  them  are  political  institutions,  with  all  the  faults  of  admin- 
istration thereto  pertaining.  Even  when  the  institutions  are  privately 
endowed,  as  long  as  the  management  is  not  in  the  hands  of  the  univer- 
sity itself,  innumerable  and  often  previously  inconceivable  difficulties 
are  put  in  the  way  of  clinical  teachers.  Continuity  of  service,  for  in- 
stance, is  rarely  possible,  and  such  a  thing  as  a  graded  staff,  directly 
responsible  to  each  professor — an  arrangement  absolutely  indispensable 
for  satisfactory  clinical  work — is  almost  unknown. 

It  is  obvious  that  if  those  who  teach  the  clinical  subjects  have  to 
make  their  living  from  practise  they  will  be  compelled  to  direct  their 
activities  so  as  not  to  interfere  with  practise.  Wlien  one  considers  the 
amount  of  time  and  energy  which  the  patients  of  a  successful  city  prac- 
titioner use  up,  when  one  remembers  the  large  bibliography  in  English, 
French  and  German  pertaining  to  the  clinical  branches  which  must  be 
waded  through  weekly  and  monthly  to  keep  pace  with  one's  subject, 
and  when  one  thinks  of  the  discouraging  conditions  in  the  hospitals  in 
which  these  clinicians  are  compelled  to  visit,  he  is  forced  to  marvel  at 
the  excellent  work  which  is  daily  being  accomplished,  at  the  closeness 
in  touch  with  the  progress  of  their  subject  maintained  by  the  more 
strenuous  of  these  men,  and  at  the  fact  that  some  of  them,  in  spite  of 
all  these  unfavorable  circumstances,  actually  make  contributions  to  the 
advance  of  science  by  their  original  work.  It  says  much  for  the  energy 
and  character  of  the  men  who  are  attracted  by  clinical  medicine,  sur- 


230  MEDICAL   BESEABCH   AND   EDUCATION 

gery  and  obstetrics  in  this  country.  If  so  much  can  be  accomplished 
under  such  adverse  circumstances,  what  might  not  be  done  by  such  men 
if  the  subjects  of  the  last  two  years  were  placed  upon  a  real  university 
basis  ?  I  should  like  to  see  what  the  result  would  be  if  men  with  these 
capacities  were  bred  to  university  careers,  were  placed  in  charge  of 
hospitals  especially  constructed  and  endowed  for  university  purposes, 
and  were  suflficiently  paid  to  permit  them  to  devote  their  whole  time  and 
strength  to  teaching  and  investigating  in  such  hospitals. 

A  Real  University  School 

If  one  attempts  to  portray  the  characters  of  a  school  of  medicine 
developed  throughout  according  to  true  university  ideals  he  will  find 
it  necessary  to  depict  conditions  which,  as  yet,  exist  nowhere  in  com- 
pleteness. In  a  modern  university  an  essential  feature  is  the  combina- 
tion of  the  academia  with  the  scliola.  The  university  must  be  a  center 
of  original  research,  as  well  as  a  place  of  instruction.  An  institution 
which  attempts  no  more  than  the  imparting  of  knowledge  already 
acquired  to  its  students  is  not  worthy  of  the  name  of  university.  It  is 
merely  a  college  or  seminary.  A  true  university  is  made  up  of  a  group 
of  scholars  who  are  not  only  familiar  with  the  results  of  previous  inves- 
tigations, but  who,  endowed  with  unusual  capacities  and  skilled  in  the 
methodology  of  their  respective  sciences,  invade  new  territories,  search- 
ing diligently  for  new  facts.  Methods  already  devised  are  used  when 
they  are  sufficient;  new  methods  are  invented  when  old  ones  fail.  Each 
scholar  works  for  the  sake  of  truth  in  his  own  department.  He  does 
not  permit  himself  to  consider  too  attentively  the  applicability  of  the 
truths  he  discovers  to  conditions  belonging  to  other  departments  of 
knowledge.  He  may  not  be  too  regardful  of  the  compatibility  of  a  new 
fact  with  the  preconceived  ideas  held  by  himself  or  by  others.  He  will 
do  well  not  to  spend  too  much  time  thinking  of  the  effect  of  a  new 
fact  upon  the  desires  or  the  fears  of  the  people.  He  must  have  a  pro- 
found belief  in  the  ultimate  value  of  truth,  no  matter  how  unpalatable 
it  may  be,  or  how  useless  it  may  seem  to  those  who  live  at  the  time  it  is 
found  out. 

Each  leader  in  a  department  of  a  true  university  is  both  a  teacher 
and  an  investigator.  The  really  great  teachers  have  always  been  inves- 
tigators. The  really  great  investigators  have  always  been  teachers, 
though  not  always,  perhaps,  of  large  groups  of  students,  nor  always,  it 


MEDICINE    AND    THE    UNIVERSITIES  231 

must  be  admitted,  in  their  own  generation.  It  is  highly  desirable  that 
the  two  faculties  of  teaching  and  discovering  be  combined  in  every 
university  professor.  There  may  be  a  place  for  the  non-investigating 
teacher  in  a  college  or  seminary,  but  he  is  certainly  out  of  his  sphere  as 
the  leader  of  a  department  in  a  university.  The  great  investigator,  on 
the  other  hand,  who  can  not  teach  students  directly,  may  profitably  be 
housed  and  cared  for  in  a  university  for  the  sake  of  the  contributions 
which  he  will  make  to  knowledge  and  the  prestige  his  work  will  bring 
to  the  institution,  but  the  department  in  which  he  works  should  also 
be  represented  by  other  men  who  can  both  investigate  and  teach.  I  am 
convinced  that  the  influence,  for  any  considerable  length  of  time,  of  a 
non-investigating  teacher  can  not  fail  to  be  actually  harmful  to  a 
student.  The  student  may  possibly  acquire  large  stores  of  information, 
but  he  will  not  make  progress  in  independent  work  or  in  independent 
thought ;  indeed  his  powers  in  this  direction  will  be  inhibited,  if  not  in 
time  wholly  obliterated.  No  less  pernicious  to  the  student  would  be  the 
effect  of  an  investigator  whose  personality  is  repellent  and  non-sym- 
pathetic and  who  has  little  or  no  capacity  to  interest  students  in  his 
subject,  to  inspire  their  enthusiasm  for  work,  or  to  train  them  in  accu- 
rate observation,  sound  reasoning  and  vivid  imagination. 

If  these  views  of  what  a  university  professor  should  be  hold  for  the 
faculties  of  arts,  literature  and  science — and  it  will,  I  believe,  be 
generally  granted  that  they  do — why  should  they  not  also  hold  good  for 
the  professional  faculties  of  law  and  medicine?  Surely  there  is  need 
in  these  faculties  for  professors  of  the  same  high  type. 

It  is  generally  taken  for  granted  that  in  the  philosophic  faculty  of 
a  university  a  professor  shall  give  the  whole  of  his  time  and  all  of  his 
strength  (aside  from  necessary  recreation)  to  work  for  the  university. 
The  professor  of  economics  does  not  give  a  part  of  his  time  to  the  uni- 
versity and  the  other  part  to  the  financing  of  city  banks.  The  professor 
of  mathematics  would  scarcely  be  permitted  to  give  his  forenoons  to 
calculus,  quaternions  or  the  teaching  of  "groups"  in  the  class-room, 
and  his  afternoons  to  the  work  of  actuary  for  a  transcontinental  railway, 
or  to  the  calculation  of  stresses  and  strains  for  a  bridge  manufacturer; 
nor  would  the  university  retain  as  its  professor  of  chemistry  one  who 
divided  his  time  between  the  university  laboratory,  on  the  one  hand,  and 
a  factory  for  the  preparation  of  aniline  dyes,  or  a  huge  establishment  for 
the  manufacture  of  drugs  in  a  commercial  way,  on  the  other.    Imagine 


232  MEDICAL   BESEABCH   AND   EDUCATION 

the  condition  which  would  exist  if  the  university  said  to  its  professor  of 
economics :  "  "We  shall  be  glad  to  have  you  as  our  professor  of  this  sub- 
ject, provided  you  are  willing  to  do  the  teaching  we  ask  of  you  without 
direct  remuneration.  Your  position  in  the  university  will  make  you  so 
well  and  favorably  known,  that  jon  will  easily  be  able  to  secure  financial 
responsibilities  in  the  city  which  will  give  you  a  far  larger  income  than 
we  could  afford  to  pay  you."  Or  if  the  president  and  trustees  made  a 
proposition  to  the  professor  of  chemistry  that  he  be  paid  $1,500  per  year 
to  take  charge  of  the  teaching  and  investigation  in  the  chemic  labora- 
tories, it  being  pointed  out  to  him  that  the  prestige  of  a  university  pro- 
fessorship will  enable  him  to  secure  lucrative  positions  as  commercial 
chemist  to  four  or  five  manufacturing  concerns  in  the  city  in  which  he 
lives,  or  as  analyst  to  baking-powder  companies  and  manufacturers  of 
pure  food  preparations,  some  of  the  trustees  taking  the  stand  that  the 
intimate  contact  thus  gained  with  chemistry  as  practically  applied  in 
the  business  world  is  not  only  desirable  for  the  professor,  but  absolutely 
essential  in  order  that  his  influence  upon  his  students  may  not  be  too 
academic  !  Which,  think  you,  the  university  interests  or  the  other  inter- 
ests, would  get  the  lion's  share  of  the  time  and  energy  of  these  pro- 
fessors, especially  if  they  happened  to  have  families  with  tastes  as 
expensive  as  those  of  the  average  American  family  of  the  better  class? 
What  think  _you  would  be  the  rate  of  progress  in  original  work  in  the 
sciences  of  political  economy  and  chemistry  in  a  university  so  consti- 
tuted? And  yet  there  is  not  a  medical  faculty  in  a  university  any- 
where in  America  where  this  plan  is  not  followed,  at  least  for  some  of 
the  chairs.  The  law  faculties  have  fared  somewhat  better,  perhaps,  but 
I  am  told  that  the  condition  obtains  also  in  the  majority  of  these.  Until 
this  is  wholly  changed  we  can  scarcely  hope  for  the  disappearance  of 
that  opprobrium  which,  it  can  not  be  denied,  attaches  to  the  so-called 
professional  faculties  of  our  universities.  Until  a  new  regime  is  entered 
upon,  we  must,  for  these  faculties,  fain  be  content  with  work  less  in 
quantity  and  poorer  in  quality  than  is  consistent  with  the  ideals  and 
dignity  of  a  true  university. 

It  is  a  rather  prevalent  opinion  that  the  reason  the  philosophical 
faculties  of  universities  have  been  regarded  as  of  higher  standing  than 
the  professional  faculties  and  the  faculties  of  technical  schools  is  to  be 
found  entirely  in  that  aristocratic  prejudice  which  favors  traditional 
"learning"  and  holds  itself  aloof  from  science,  and  especially  from 


MEDICINE    AND    THE    UNIVEESITIES  233 

science  as  applied  in  professional  and  industrial  life.  I  have  as  little 
sympathy  as  any  one  with  those  narrow-minded  academicians  who 
believe  that  the  only  learning  and  the  only  culture  worthy  of  the  name 
are  to  be  gained  by  a  study  of  the  ancient  languages  and  literatures. 
Indeed,  I  unhesitatingly  join  hands  with  those  who  maintain  that  any 
academic  training  which  does  not  include  the  inculcation  of  the  "fair, 
faithful  and  fearless  spirit"  of  modern  scientific  inquiry  fails  of  the 
best  purpose  of  education.  What  is  more,  I  am  convinced  that  a  reason- 
able admixture  of  natural-science  studies,  even  if  chosen  from  the 
domain  of  applied  science,  with  the  courses  in  languages,  literature, 
history  and  philosophy,  will  yield  cultural  results  of  a  far  higher 
order  than  can  be  obtained  where  programs  from  which  natural  science 
is  excluded  are  followed.  For  only  through  the  study  of  the  natural 
sciences  can  we  escape  that  dominant,  though  unwitting  egoism  which 
makes  man  the  center  of  the  universe.  Our  whole  education  tends  too 
much  to  distort  the  human  relation.  "Man  so  readily  deifies  himself, 
and  so  gladly  permits  others  to  deify  him :  he  occupies  himself  prefer- 
ably with  himself,  with  his  own  intellect  and  its  products,  he  calls  his 
own  intellect  divine;  takes  pleasure  in  worshiping  his  own  image  and 
imagines  that  at  the  same  time  he  is  exhibiting  a  proper  degree  of 
humility."  It  is  with  great  difficulty  that  human  beings  resign  them- 
selves to  the  scientific  view  of  man  and  the  universe.  It  is  not  easy  at 
first,  as  Billroth  says,  to  admit  that  even  the  greatest  human  being  is  a 
mere  atom  compared  with  the  totality  of  natural  phenomena,  or  to 
hear  the  whole  human  race  described  as  but  one  group  of  animals, 
active  but  for  a  relatively  short  time  upon  the  earth's  surface,  and,  in 
comparison  to  the  whole  universe,  vanishing  almost  into  nothing. 
"  Man  may  willingly  humble  himself  before  his  God,  but  he  always 
values  himself  much  higher  than  the  whole  of  nature."  There  is  a 
side  of  culture  which  only  the  study  of  the  natural  sciences  can  give. 
A  sanity  and  a  balance  are  derivable  from  them  which  can  scarcely  fail 
to  be  lacking  when  the  so-called  "  humanities  "  only  are  studied. 

Though  it  may  be  true  that  prejudice  born  of  the  old  monastic 
influence  still  shackles  the  universities,  and  that  there  has  been  in  the 
past  a  "  discrimination  among  learnings,"  I  can  not  believe  that  it  is 
lack  of  democracy  alone,  or  predilection  for  tradition  alone,  which 
accounts  for  the  slowness  with  which  in  the  first  place  so-called  pure 
science  and  later  the  scientific  professions  gained  recognition  among 


234  MEDICAL   BESEABCH   AND    EDUCATION 

the  people  and  in  the  universities,  or  for  the  opprobrium  that  undoubt- 
edly does  attach  still  in  many  minds  to  the  terms  professional  school 
or  technical  school,  when  compared  with  the  school  of  philosophy.  The 
cause  lay  much  deeper.  It  was  necessary  for  the  professional  schools 
and  the  technical  schools  to  win  their  spurs.  So  long  as  natural  science 
remained  merely  the  recreation  of  the  dilettante,  so  long  as  medicine 
continued  to  be  chiefly  an  empiric  art,  and  technology  the  passing  on 
of  rule  of  thumb,  these  subjects  were  not  coequal  with  their  elder  sister. 
No  people  began  its  culture  with  the  exact  study  of  the  natural  sci- 
ences; these  could  come  to  development  only  after  the  prolonged 
influence  of  language,  art,  religion,  law  and  politics.  So  soon  as 
physics,  chemistry  and  biology  began  to  make  the  tremendous  strides 
forward  which  characterized  the  last  century  they  were  taken  out  of 
the  medical  faculties  and  incorporated  in  the  philosophic  faculties  of 
the  universities  with  the  happy  results  familiar  to  all. 

Eecently,  applied  science  has  won  its  place.  The  enormous  expan- 
sion of  commerce  and  industry  has  compelled  the  establishment  of 
great  technical  schools.  The  old  method  of  apprenticeship  no  longer 
suffices  for  the  training  of  men.  It  has  become  necessary  to  save 
time  and  energy,  and  to  make  the  instruction  more  extensive  and  more 
thorough  by  education  in  institutions  dedicated  to  applied  sciences. 
The  inventive  mechanic,  the  engineer  and  the  electrician  have  revolu- 
tionized the  world  within  our  own  memories;  if  we  live  out  our  three- 
score and  ten  we  may,  perhaps,  be  permitted  to  witness  even  greater 
transformations.  In  the  schools  of  engineering,  not  only  are  the 
known  applications  of  science  taught,  but  brilliant  minds  are  constantly 
at  work  devising  ever  new  and  still  more  wonderful  applications. 
America,  especially,  has  reason  to  be  proud  of  the  advances  she  has 
made  in  technologic  education.  A  foreigner  commenting  upon  our 
educational  system  has  made  the  statement  that  "  the  engineering 
profession  is  to-day,  upon  the  whole,  the  best  educated  in  America." 
The  degree  of  doctor  of  engineering  from  a  good  university  or  institute 
of  technology  commands  full  respect.  I  shrink  from  comparing  it 
with  the  degree  of  doctor  of  medicine  given  by  many  of  our  universities 
or  medical  schools.  The  governments  of  Germany  and  Austria  have 
made  "  the  doctorates  of  engineering  and  of  the  applied  sciences,  and 
the  institutions  permitted  to  confer  them,  coequal  with  the  doctorates 
of  philosophy  and  their  conferring  universities."     The  head  of  the  great 


MEDICINE    AND    THE    UNIVEBSITIES  235 

German  Polytechnicum  has   been  made  a   Eector  Magnifieus,   proof 
enough  that  the  democracy  of  learning  is  gaining  ground.- 

The  way  to  get  the  highest  recognition  is  to  deserve  it;  the  way  to 
get  rid  of  the  opprobrium  attaching  to  the  professional  schools  is  to 
remove  the  cause  of  it.  In  medicine  this  cause  is  fast  disappearing. 
Anatomy,  physiology  and  pathology  have  followed  physics,  chemistry 
and  biology  into  the  university.  Large  and  well-equipped  laboratories 
and  libraries  are  devoted  to  these  subjects.  Large  amounts  of  money 
have  been  given,  so  that  the  professors  and  their  assistants,  though  as 
yet  inadequately  remunerated,  are  sufficiently  paid  to  permit  men  who 
will  despise  certain  of  the  delights  of  life  and  live  laborious  days  to 
follow  these  subjects  as  careers.  Students  are  taught,  and  important 
discoveries  are  being  made  in  these  branches.  The  physiologist  is  as 
fully  recognized  as  the  philologist.  The  men  and  their  subjects  are  on 
an  equality,  not  because  they  have  been  made  so  by  edict  of  sovereign 
or  ruling  of  university  presidents,  or  vote  of  trustees,  but  because  they 
really  are  so.  There  is  no  reason  why  internal  medicine,  surgery, 
obstetrics  and  certain  other  branches  should  not  be  similarly  elevated; 
on  the  contrary,  for  the  sake  of  people  who  need  help  in  time  of  illness, 
for  the  sake  of  the  medical  profession,  on  account  of  our  universities 
and  for  the  prestige  of  the  science  of  the  nation,  there  is  every  reason 
for  that  elevation.  And  this  would  speedily  be  brought  about  if 
universities  and  their  benefactors  fully  understood  the  situation. 

How  CAN  A  Semi-university  School  be  Transformed  into 
A  Eeal  University  School? 

By  putting  all  the  departments,  at  any  rate  all  the  principal 
departments,  on  a  true  university  basis.  To  do  this  several  things  are 
necessary. 

In  the  first  place,  a  very  large  sum  of  money  would  be  required,  for 
the  university  would  have  to  build  and  equip  hospitals  of  its  own, 
arranged  on  an  entirely  different  plan  from  that  adopted  in  ordinary 
charity  hospitals.  The  hospital  for  internal  medicine  would  be  built 
with  the  definite  idea  in  view  of  teaching  students  and  of  making 
original  researches  into  the  nature,  causes  and  treatment  of  disease,  in 
addition  to  caring  for  a  certain  number  of  patients.  In  other  words,  in 
addition  to  the  facilities  offered  by  any  good  hospital,  the  university 

^'Cf.  Thurston,  R.  H.,  "The  College-man  as  Leader  in  the  World's  Work," 
Popular  Science  Monthly,  Vol.  IX.,  1902,  pp.  346-359. 


236  MEDICAL   BESEAECH   AND   EDUCATION 

hospital  for  medicine  would  have  to  house  a  university  department  of 
medicine  with  its  teaching  and  research  laboratories.  A  second  hos- 
pital would  do  the  same  for  surgery;  a  third  for  obstetrics.  Two  mil- 
lion dollars  for  each  of  these  hospitals  would  not  be  an  excessive  sum 
to  make  the  initial  installment  and  to  endow  the  university  department. 
In  order  to  secure  such  a  large  amount  of  money  it  is  obvious  that 
university  presidents  and  boards  of  trustees  must  be  fully  convinced  of 
its  necessity,  for  only  when  this  is  the  case  will  wealthy  men  be  willing 
to  contribute  such  immense  amounts  to  the  universities  for  this  specific 
purpose. 

If  such  hospitals  could  be  obtained,  and  such  professorships  en- 
dowed, the  men  engaged  to  work  in  them  should  be  chosen  with  the 
same  care  as  to  talents,  attainments  and  personality  as  is  exercised  in 
the  choice  of  any  other  professor  in  the  university.  The  men  chosen 
should,  like  other  university  professors,  give  their  whole  time  and 
energy  to  the  work  of  the  university,  to  teaching  in  the  hospitals  and 
to  investigating  in  the  hospitals.  They  should  be  men  who  have 
already  made  important  contributions  to  knowledge  and  who  are  likely 
to  continue  doing  so  for  the  next  twenty  years.  They  should  be  well 
paid  by  the  university.  They  should  not  engage  in  private  practise, 
even  if  the  university  has  to  pay  them  double  the  ordinary  salary  now 
paid  to  a  university  professor  to  retain  them  wholly  in  the  university 
work.  If  any  patients  at  all,  outside  of  the  hospitals,  were  seen  in 
consultation,  and  there  is  some  force  in  the  argument  that  the  well- 
to-do  public  should  at  least  in  some  rare  and  difficult  cases  be  permitted 
to  profit  by  the  opinion  and  advice  of  the  university  professor,  the  fees 
received  from  them  might  be  contributed  to  the  budgets  of  the  hospitals 
themselves,  in  order  to  remove  all  temptation  from  the  staff. 

The  objection  is  sometimes  raised  that  university  professors  who 
gave  their  whole  time  to  teaching  and  investigating  in  hospitals  would 
not  come  into  contact  in  hospitals  and  dispensaries  with  the  kind  of 
patients  and  the  types  of  diseases  which  are  met  with  by  the  practi- 
tioner in  private  practise,  and  that  accordingly  the  student  would  not 
be  taught  how  to  deal  with  private  patients  nor  how  to  recognize  and 
treat  the  cases  which  he  has  actually  to  deal  with  later  himself.  This 
argument  appears  plausible  until  it  is  more  closely  examined.  The 
character  of  hospital  patients  is  gradually  changing  and  the  clinician 
who  confines  himself  to  work  in  hospital  wards  and  dispensaries  does 


MEDICINE    AND    THE    UNIVEESITIES  237 

actually  in  these  latter  days  see  many  more  of  those  people  and  of  those 
varieties  of  complaints  previously  seldom  seen  outside  of  family  prac- 
tise. On  the  other  hand,  in  a  medical  college  in  which  the  clinical 
professors  engage  in  private  practise,  the  students  are  not  taken  by 
their  teachers  into  the  homes  of  the  patients,  the  private  patients  are 
not  shown  and  the  "  private-practise  "  diseases  are  not  demonstrated  or 
studied  in  any  practical  way.  The  influence  of  his  "  private  practise  " 
may  be  visible,  perhaps,  in  some  special  savoir  faire  manifested  by  the 
instructor  in  dealing  with  patients;  too  often  it  reveals  itself  in  the 
more  superficial  examination  of  the  patient,  the  more  hurried  considera- 
tion of  the  case,  the  less  rigorously  established  diagnosis  and  the 
writing  of  a  prescription  ut  aliquid  fiat,  which  the  exigencies  of  private 
practise  are  said  sometimes  to  entail.  Even  if  it  were  granted — and 
I,  for  one,  am  ready  to  grant  it — that  something  difficultly  definable 
but  of  real  value  to  the  learner  emanated  from  the  teacher  who  spends 
a  large  portion  of  his  time  in  private  practise  outside  of  hospitals, 
which  is  lacking  in  the  professor  who  gives  his  whole  time  and  energies 
to  the  patients  in  the  university  hospitals  and  work  in  the  laboratories 
adjacent  to  the  wards,  would  it  be  comparable  with  the  increase  in 
scientific  spirit  which  the  student  might  reasonably  be  expected  to  gain 
from  contact  with  a  professor  who,  besides  having  the  capacity  for  the 
best  kind  of  work,  has  the  time,  energies  and  opportunities  to  penetrate 
into  the  innermost  secrets  of  disease  in  a  manner  precluded  by  the 
demands  of  private  practise?  If  we  had  to  give  up  one  influence  or 
the  other,  would  there  be  any  doubt  as  to  which  we  could  the  more 
safely  disregard?  Btit  we  need  not  be  deprived  of  either  influence, 
for  in  large  cities  both  should  be  available  and  the  students  should  be 
permitted  to  profit  by  both. 

It  is  not  necessary  or  desirable  (aside  from  being  impossible)  that 
a  student,  during  the  two  or  three  years  spent  in  clinical  work  in  the 
medical  school,  should  see  all  kinds  of  diseases,  or  even  hear  of  all  the 
symptoms  or  of  all  the  methods  of  treatment  which  have  been  advised. 
It  is  important  that  he  should  be  taught  systematic  methods  of  accurate 
observation  and  investigation;  that  he  should  be  taught  how  to  get  at 
and  how  to  relate  the  experiences  of  his  predecessors  in  interpreting 
his  findings,  how  to  make  judicious  prophecies  for  the  future  from  a 
consideration  of  the  past,  and  how  to  plan  out  a  rational  mode  of  treat- 
ment.     He  needs  thorough,  conscientious  drill  in  the  fundamental 


238  MEDICAL   BESEABCR   AND    EDUCATION 

methods  of  examination,  preferably  on  not  too  large  a  number  of 
patients,  for  a  long  time  before  he  views  the  kaleidoscopic  transforma- 
tions of  the  "  20  patients  per  hour "  clinic,  and  is  treated  to  imposing 
demonstrations  in  "  snap-shot "  medical  diagnosis  or  spectacular  amphi- 
theater surgery.     Routine  lernt  man  allzuschnell. 

I  would  not  be  misunderstood  in  this  matter.  No  one  values  per- 
haps more  highly  than  I  the  rich  and  varied  experience  of  the  really 
great  practitioner  of  private  practise,  nor  is  any  one  more  cognizant  of 
the  fact  that  many  busy  practitioners  are  enthusiastic,  careful,  thor- 
ough, methodical  teachers.  There  is  a  proper  place  for  this  type  of 
man,  as  well  as  for  the  university  professor,  in  a  real  university  school. 
The  finding  of  that  place  is  all-important  for  the  future  welfare  of 
medicine.  The  student  at  the  beginning  of  his  clinical  work  should  be 
thoroughly  drilled  in  all  the  methods  of  examination,  and  should  study 
a  few  cases  laboriously,  applying  with  strict  rigor  the  methods  he  has 
learned;  later  he  might  more  safely  be  permitted  rapidly  to  widen  his 
clinical  experience  by  being  introduced  to  a  greater  number  and  a 
greater  variety  of  patients.  My  own  opinion  is  that  the  work  of  the 
present  third  year  might  be  taught  by  professors  and  instructors  who 
give  their  whole  time  to  university  hospitals,  and  that  those  associated 
clinical  professors  and  instructors  who  also  engage  in  private  practise 
might  teach  in  other  hospitals  in  the  last  year  of  the  medical  student's 
course.  It  is  very  desirable  that  the  better  practitioners  should  con- 
tinue to  visit  in  hospitals  for  the  good  of  themselves  and  of  their 
patients,  as  well  as  for  the  good  of  medical  students.  University  hos- 
pitals for  research  will  of  necessity  be  few  in  number,  and  will  by  no 
means  replace  the  hospitals  which  at  present  exist.  Particularly  in  the 
clinical  specialties  must  the  private  practitioner  be  retained  as  a  teacher, 
for  but  few  universities  will  have  the  endowment  necessary  to  maintain 
full  university  chairs  in  clinical  departments  other  than  those  of  medi- 
cine, surgery,  obstetrics  and  perhaps  psychiatry. 

The  great  discoveries  which  have  been  made  in  practical  medicine 
recently  have  resulted  largely  from  the  introduction  of  the  experimental 
method.  There  is  no  doubt  in  my  mind  that  it  is  to  experimental 
medicine  that  we  must  look  for  the  advances  of  the  future.  Had  it  not 
been  for  Pasteur's  brilliant  discoveries  and  the  ingenious  methods 
devised  by  Koch,  we  should  not  have  had  Lister's  work  and  the  aseptic 
surgery  of  to-day,  nor  would  a  disease  like  diphtheria,  formerly  so  fatal. 


MEDICINE    AND    THE    UNIVERSITIES  239 

have  been  robbed  of  its  terrors  through  the  introduction  of  an  anti- 
toxin. But  experimentation  ought  not  to  be  confined  to  those  physiol- 
ogists and  pathologists  who  are  not  clinicians.  What  we  need  above 
all  at  this  time  are  physicians  and  surgeons  trained  in  physiology  and 
pathology  who  will  spend  a  part  of  their  time  in  careful  observation  in 
the  wards  and  over  the  operating  table;  who  will  there  collect  facts 
which  will  give  them  ideas  to  be  submitted  to  experimental  test,  and 
who,  during  the  rest  of  their  time,  will  go  down  into  the  laboratories 
adjacent  to  the  wards  and  actually  make  these  experiments.  The  men 
who  do  this  should  give  their  whole  time  to  the  university. 

"Will  the  money  necessary  for  the  introduction  of  research  hospitals 
and  university  clinical  departments  be  available  ?  I  believe  firmly  that 
it  will,  and  that,  too,  in  the  very  near  future.  How  many  a  fond  and 
wealthy  parent  fifty  years  ago  would  have  endowed  one  or  more  great 
hospitals  could  he  have  saved  the  life  of  his  child  dying  of  virulent 
diphtheria!  The  organization  of  an  Institute  for  Medical  Eesearch 
in  N"ew  York,  and  of  a  Memorial  Institute  for  the  Investigation  of 
Infectious  Diseases  in  Chicago,  is  a  sign  of  the  times.  The  same  is 
true  of  the  Institute  for  Experimental  Therapy  in  Frankfort,  and  a 
number  of  others  which  I  could  name.  The  place  for  such  institutes 
is  in  the  medical  faculties  of  the  universities.  Wealthy  philanthropists 
are  recognizing  the  value  of  the  methods  of  research.  There  is  no  lack 
of  money  which  could  be  made  available  for  the  founding  of  university 
hospitals  for  research  and  for  the  maintenance  of  true  university 
departments  of  medicine,  surgery,  obstetrics  and  psychiatry,  provided 
those  in  whose  hands  it  lies  awaiting  distribution  can  be  convinced  that 
it  will  be  used  to  the  best  purposes. 

I  ask  the  cooperation  of  the  alumni  of  this  university  in  influencing 
university  faculties  and  university  presidents,  the  public  and  philan- 
thropists to  hasten  the  introduction  of  real  university  medical  schools 
in  the  different  centers  in  this  country.  The  chief  cause  of  delay,  in 
most  institutions,  lies  with  the  university  authorities.  They  are  often 
more  difficult  to  convince  than  are  their  financial  benefactors.  Univer- 
sity authorities  are  too  prone  to  magnify  the  importance  of  obtaining 
large  numbers  of  students  rather  than  to  emphasize  the  desirability  of 
an  elevation  of  standards.  They  do  not  always  recognize  fully  the 
needs  of  research,  and  are  accordingly  timid  in  their  requests  for  money 
for  investigation,  though  they  are  ever  ready  to  demand  money  to  teach 


240  MEDICAL   BESEAECE   AND   EDUCATION 

more  students.  If  this  fear  continues,  the  universities  will  lose  the 
research  institutions,  for  philanthropists  will  endow  them  as  independ- 
ent foundations.  Above  all  should  the  means  for  research  be  afforded 
to  the  professional  faculties.  Poor  professional  faculties  drag  down 
the  philosophic  faculties;  adequate  schools  of  medicine  and  law  lend 
prestige  to  the  school  of  philosophy.  Were  there  any  tendency  to 
internecine  jealousies  among  the  various  faculties  of  a  university,  self- 
interest  alone  should  be  sufficient  to  suppress  it.  What  is  to  the  advan- 
tage of  one  faculty  will  not  fail  to  help  the  others.  Each  faculty  should 
vie  with  the  others  in  working  for  the  welfare  of  the  whole  university. 
Each  faculty,  therefore,  will  demand  that  all  the  faculties  are  provided 
with  the  facilities  for  seeking  the  truth  according  to  the  most  rigorous 
methods,  and  independent  of  its  apparent  use  or  harm.  The  more 
intense  the  desire  of  the  people  for  truth  and  clearness  becomes,  the 
more  pressing  will  this  demand  grow. 


SOME    TENDENCIES    IN    MEDICAL    EDUCATION    IN    THE 

UNITED    STATES^ 

By  Lewellts  F.  Barker,  M.D., 

Peofessoe  op  Medicine  in  The  Johns  Hopkins  Univeesitt  and  Physician-in- 
Chief  to  The  Johns  Hopkins  Hospital,  Baltimoee 

That  brilliant  and  humorous  journalist-novelist,  Mr.  Arnold  Ben- 
nett,  in  his  essay  on  "  Success  "  says :  "  I  feel  that  it  is  as  dangerous 
to  tell  the  truth  about  success  as  it  is  to  tell  the  truth  about  the  United 
States ;  but  being  thoroughly  accustomed  to  the  whistle  of  bullets  round 
my  head,  I  will  nevertheless  try."  Whatever  grain  of  fact  there  may 
be  in  his  allusion,  certain  it  is  that  in  the  United  States  themselves 
there  is  a  strong  tendency  at  the  present  time  to  try  to  tell  the  whole 
truth  about  medical  conditions  there.  As  regards  medical  education, 
the  men  who  are  really  interested  in  the  matter  are  making  no  attempt 
to  blink  the  facts.  Those  who  write  and  speak  seem  determined  to  deal 
with  the  subject  in  a  thorough  and  candid  manner.  The  discussion  has 
led,  and  is  leading,  to  marked  changes  in  the  standards  and  circum- 
stances of  medical  instruction,  medical  research  and  medical  practise 
"  on  the  other  side  of  the  line."  To  some  of  the  truth  concerning 
medical  conditions,  and  to  some  of  the  burning  questions  at  issue,  I 
desire  to  point. 

The  Passing  of  the  Inferior  Medical  Schools 

If  you  compare  medical  education  in  the  United  States  twenty  years 

ago  with  what  it  is  to-day,  you  can  not  help  but  be  impressed  with  the 

remarkable  change  which  has  taken  place.     The  period  has  witnessed 

a  reform  which  is  noteworthy  in  history.     During  the  past  decade, 

especially,  there  has  been  a  steady  decrease  in  the  number  of  inferior 

medical  schools  and  an  elevation  of  standards  in  the  better  schools. 

The  country  has  passed  rapidly  from  a  stage  in  which  the  proprietary 

medical  school  was  dominant  to  one  in  which  all,  or  nearly  all,  of  the 

better  medical  schools  are  the  medical  departments  of  universities. 

^  Based  on  remarks  made  at  the  convocation  exercises  at  McGill  University, 
Montreal,  June  5,  1911.  Published  in  the  Journal  of  the  American  Medical 
Association,  1911.     [The  article  in  the  Journal  is  abridged.] 

17  241 


242  MEDICAL   BE  SEARCH   AND   EDUCATION 

It  was  not  easy  to  bring  such  a  change  about.  Every  reform  entails 
hardships ;  attempts  at  betterment  invariably  excite  some  animosity  and 
antagonism.  It  says  much  for  the  spirit  of  the  men  in  the  medical 
profession  and  in  the  faculties  of  the  medical  schools  that  the  majority 
of  them  have  kept  in  mind  the  welfare  of  the  profession,  of  medical 
education  and  of  human  service,  and  have  been  so  ready  to  sacrifice 
their  private  interests  when  such  self-denial  was  demanded. 

Reduction  in  the  Number  of  Medical  Schools 

The  total  number  of  medical  schools  in  the  United  States  is  still 
being  rapidly  reduced.  This  reduction  is  taking  place  in  two  ways: 
first,  by  extinction  of  the  most  unfit;  and,  second,  by  the  merging  of 
numbers  of  feebler  schools  into  larger  and  more  efficient  institutions. 
In  1904  there  were  166  medical  colleges  in  the  United  States.  Within 
the  succeeding  lustrum  the  purificative  movement  had  made  such  prog- 
ress that  in  1909,  though  twenty-five  new  medical  schools  had  been 
organized,  forty-three  had  been  closed,  sixteen  by  extinction  and  the 
balance  by  merger  with  other  schools.  This  process  of  suppression  of 
schools  and  of  amalgamation  of  schools  has  been  continuing  since,  and 
it  is  hoped  that  the  examples  set  by  the  medical  schools  in  Louisville, 
Kentucky,  and  in  Cincinnati  may  be  followed,  especially  in  large  cities 
like  Baltimore,  Chicago  and  Philadelphia.  The  absurdity  of  having 
more  than  a  dozen  medical  schools  in  a  city  like  Chicago  is  obvious. 
Imagine  the  medical  state  of  Berlin,  Vienna  or  Paris  were  the  powers 
of  medical  instruction  there  similarly  disintegrated ! 

Increased  Requirements  for  Admission.     Elevation  of 
Standards  in  Teaching 

This  reduction  in  the  number  of  medical  schools  with  survival  of 
the  better  has  been  due  less  to  direct  attacks  on  the  poorer  schools  than 
to  a  rapid  elevation  of  the  standards  of  admission  to,  and  improvement 
of  the  teaching  in,  the  better  institutions.  Some  day  the  history  of 
this  advance  should  be  carefully  written.  Intricate  and  complex  as 
have  been  the  factors  of  this  progress,  we  may  easily,  on  attention,  dis- 
engage the  main  influences  which  have  been  responsible.  Among  them, 
it  is  now  generally  admitted,  were  ( 1 )  the  initiation  of  a  graded  course 
as  far  back  as  1859  by  the  medical  department  of  Northwestern  Uni- 
versity in  Chicago,  (2)  the  adoption  of  this  and  the  gradual  increase 


TENDENCIES    IN    MEDICAL    EDUCATION  243 

of  admission  requirements  and  improvement  of  the  curriculum  in 
which  schools  like  Harvard  set  the  pace  and,  further,  (3)  the  step  taken 
in  1893  in  the  organization  of  the  Johns  Hopkins  Medical  School.  The 
latter,  an  integral  part  of  a  strong  university,  opening  its  doors  to 
students  in  that  year,  made  several  departures  from  established  custom. 
It  announced  that  candidates  must  present,  as  a  prerequisite  for  admis- 
sion, evidence  of  having  had  an  education  corresponding  to  that  re- 
quired for  the  baccalaureate  degree  in  a  good  college  of  liberal  arts; 
in  addition,  either  when  working  toward  this  degree  or  subsequently, 
a  year's  laboratory  training  in  physics,  chemistry  and  biology  must 
have  been  completed  and  a  fair  reading  knowledge  of  the  French  and 
German  languages  acquired.  With  an  endowment,  part  of  which  was 
given  on  condition  that  these  requirements  for  admission  be  maintained 
and  that  women  be  admitted  on  equal  terms  with  men,  this  school  was 
able  not  only  to  establish  well-equipped  laboratories  of  anatomy,  physi- 
ology and  pharmacology  in  addition  to  the  laboratory  of  pathology 
which  had  been  built  earlier,  but  to  secure  a  group  of  men  for  the  non- 
clinical chairs  who  had  been  trained  especially  in  their  respective 
sciences,  who  had  no  desire  to  practise  medicine  and  who  were  willing, 
on  salary,  to  devote  their  whole  time  and  energies  to  instruction  and 
research.  More  important  still,  an  endowed  hospital,  which  had  been 
organized  a  few  years  earlier,  stood  at  the  disposal  of  the  medical  school. 
In  the  donor's  will  it  had  been  expressly  stated  that  the  hospital  should 
"  ultimately  form  a  part  of  the  medical  school  of  the  university,"  and, 
accordingly,  the  professors  in  the  clinical  branches  in  the  medical  school 
are,  simultaneously,  the  chief  of  the  clinics  in  the  hospital,  and  the 
professor  of  pathology  the  head  of  the  pathologic  laboratory  to  which  the 
clinics  send  their  dead. 

Since  that  time  the  medical  departments  of  many  other  universities 
have  increased  their  equipment  and  provided  larger  means  for  pro- 
fessorships, especially  in  the  non-clinical  branches;  several  schools  now 
require  a  college  degi-ee  for  admission;  no  less  than  twenty-seven 
schools  demand  as  a  minimum  for  entrance  two  or  more  years  of  work 
in  a  college  of  liberal  arts — a  gratifying  showing  when  it  is  recalled 
that  up  to  1904  less  than  two  per  cent,  of  all  medical  colleges  required 
more  than  a  high-school  education  as  preparation.  The  success  of  the 
better  schools,  the  enthusiasm  of  the  students  trained  in  them,  the 
opportunities  which  have  opened  up  for  these  students  after  graduation. 


244  MEDICAL   BESEABCH   AND   EDUCATION 

the  scientific  investigations  leading  to  publication  which  have  been 
carried  on — all  have  contributed  to  spur  other  medical  schools  in  dif- 
ferent parts  of  the  country  to  emulate  the  examples  set. 

There  have  been  two  main  difficulties:  (1)  the  financial  one  of 
equipping  the  expensive  laboratories  of  anatomy,  physiology  and  path- 
ology and  paying  the  stafE  sufficient  amounts  to  permit  them  to  devote 
their  whole  time  and  energies  to  the  work;  and  (2)  the  absence  of 
endowed  hospitals  under  the  control  of  medical  schools  or  universities, 
into  the  wards,  dispensaries  and  laboratories  of  which  students  could  be 
taken  actually  to  participate  in  the  routine  work  of  diagnosis  and 
treatment.  * 

Lively  discussions  on  (1)  medical  education,  (2)  the  preliminary 
requirements  therefor,  (3)  the  endowments  needed,  (4)  the  character 
of  the  staff  necessary,  (5)  the  importance  of  university  supervision  and 
(6)  the  necessity  of  laboratory  and  bedside  instruction  instead  of  pre- 
ponderantly didactic  teaching,  did  much  to  spread  a  new  gospel.  These 
debates  were  carried  on  by  the  faculties  of  the  medical  colleges  them- 
selves, by  the  associations  of  medical  colleges,  by  the  associations  of 
American  universities  and  by  the  members  of  the  various  state  exam- 
ining boards. 

Agencies  Influential  for  Reform 

One  of  the  most  potent  of  the  agencies  for  the  elevation  of  standards 
has  been  the  Council  on  Medical  Education  of  the  American  Medical 
Association,  a  permanent  committee  of  six  men,^  appointed  expressly  for 
the  purpose  of  improving  medical  education  and  making  it  more  uni- 
form throughout  the  whole  country. 

One  interested  in  medical  education  will  have  difficulty  in  finding 
more  interesting  reading  than  the  annual  reports  of  the  conferences 
held  since  1905  by  this  council.  The  discussions  on  admission  require- 
ments, on  curricula,  on  university  relationship  and  on  the  functions  of 
state  boards,  and  the  reports  made,  (1)  on  the  standing  of  the  various 
medical  colleges,  based  on  the  failures  of  their  graduates  in  examina- 
tions before  state  boards,  and  (2)  on  the  results  of  a  personal  inspec- 
tion of  all  medical  schools  in  the  United  States,  made  by  members  of 
the  council,  have  had  an  effective  influence  in  awakening  the  profession 
to  the  pedagogic  problems  which  confront  it,  and,  especially,  to  the 
desirability  of  speedy  and  radical  reform.     The  grouping  of  medical 

'  Dr.  Bevan,  chairman ;  Dr.  Colwell,  secretary. 


TENDENCIES    IN    MEDICAL    EDUCATION  245 

schools  by  this  council  into  "acceptable"  colleges,  ''conditioned"  col- 
leges and  "  rejected "  colleges  may  be  adduced  in  illustration  of 
methods  salutary  in  results. 

The  council  has  performed  its  work  almost  wholly  through  the  cul- 
tivation of  medical  opinion ;  it  simply  gives  publicity  to  the  information 
which  it  collects.  It  has  no  power  whatever  to  dictate  to  medical 
schools  or  to  set  standards  either  for  the  schools  or  for  the  state  exam- 
ining boards,  but  it  has  so  deliberately  and  successfully,  through  the 
currency  given  to  the  results  of  its  inquiries,  worked  on  the  collective 
medical  mind  in  the  United  States,  that  a  moral  pressure,  irresistible 
in  its  coercive  force,  has  come  to  be  exerted.  A  school,  for  example, 
which  is  heralded  in  the  over  50,000  copies  of  The  Journal  of  the 
American  Medical  Association  as  one  which  turns  out  graduates  of 
whom  more  than  20  per  cent,  fail  at  the  state  licensing  examinations, 
or  another,  which,  after  personal  and  unbiased  inspection  by  members 
of  the  council,  is  classified  as  a  "  rejected  "  school,  has  a  sealed  fate. 

The  council  has  been  none  the  less  successful  for  having  avoided 
Utopian  attempts;  it  has  been  satisfied  with  a  gradual,  though  steady, 
stride  toward  attainable  ideals.  It  recognizes  the  manifold  difficulties 
of  the  pedagogic  situation,  is  aware  of  the  necessity  of  taking  time,  of 
educating  those  concerned  and,  especially,  of  the  indispensableness  of 
endowment  from  the  state,  or  from  private  funds,  if  desired  reforms 
are  to  be  instituted. 

Another  agency  which  has  been  active  and  effective  in  the  attempt 
to  help  on  the  reconstruction  of  medical  schools  in  the  United  States  is 
the  Carnegie  Foundation  for  the  Advancement  of  Teaching,  which,  in 
1908,  with  Mr.  Pritchett  as  president,  authorized  Mr.  Abraham  Flexner 
to  study  and  report  on  the  various  American  schools  of  medicine  and 
law.  Since  the  year  1876,  when  the  Vienna  surgeon,  Billroth,  pub- 
lished his  "Ueber  das  Lehren  und  Lernen  der  medicinischen  "Wissen- 
schaften,"  the  monograph  by  Abraham  Flexner^  is,  without  doubt,  the 
most  important  single  contribution  which  has  been  made  to  the  bibli- 
ography of  medical  education.  The  study  and  report  were  made  on 
the  assumption  that  medical  colleges  and  the  medical  departments  of 
universities  must  now  be  regarded  as  public-service  corporations,  and 
that  the  public  is  entitled  to  know  about  their  administration  and 
development,  on  both  the  financial  and  educational  sides,  for  only 

"Flexner,  A.,  "Medical  Education  in  the  United  States  and  Canada."  a 
report  to  the  Carnegie  Foundation  for  the  Advancement  of  Teaching,  1910. 


246  MEDICAL   BESEABCH   AND   EDUCATION 

through  a  reasonable  publicity  can  progress  in  medical  education  be 
hoped  for. 

The  report  contains  a  history  of  medical  education  in  the  United 
States  and  Canada,  comments  on  its  present  status,  gives  a  forecast  of 
possible  progress  in  the  future  and  describes  more  or  less  in  detail  each 
medical  school  in  existence  in  the  various  states  and  in  the  Canadian 
provinces  at  the  time  it  was  made.  Mr.  Flexner  concludes  that  during 
the  past  quarter  of  a  century  there  has  been  an  enormous  over-produc- 
tion of  uneducated  and  badly  trained  medical  practitioners,  and  that 
this  over-production  of  poorly  trained  men  is  mainly  due  to  the  exist- 
ence of  a  great  number  of  "commercial"  schools  attracting  into  the 
study  of  medicine  unprepared  boys  who  should  have  taken  up  industrial 
occupations.  The  poorer  schools  have  failed,  it  is  asserted,  to  appre- 
ciate the  remarkable  advance  which  the  better  schools  have  made  and 
they  underestimate  the  amount  of  money  required  to  defray  the  expense 
of  teaching  by  modern  methods.  Stress  is  laid  on  the  fact  that  a  hos- 
pital under  complete  educational  control  is  as  necessary  to  a  medical 
school  as  is  a  laboratory  of  chemistry  or  pathology.  A  great  reduction 
in  the  number  of  medical  schools  is  recommended,  better  equipment 
and  better  conduct  asked  of  those  that  remain,  and  the  graduation  from 
each  of  fewer  physicians,  but  of  better  quality,  demanded.  Methods  of 
properly  articulating  the  medical  school  with  the  other  parts  of  a  uni- 
Tersity  and  with  the  general  system  of  education  are  outlined.  The 
university  which  is  willing  to  retain  a  low-grade  professional  school  for 
the  sake  of  its  institutional  completeness  is  sharply  censured.  Further, 
though  the  impossibility  of  suddenly  bringing  all  the  persisting  schools 
up  to  praiseworthy  standards  is  recognized,  it  is  urged  that  if  a  school 
can  not  rise  to  a  certain  minimum  of  educational  requirement  it  should 
cease  to  exist,  for  it  will  injure  and  not  help  civilization. 

The  tone  of  this  bulletin  is  frankly  that  of  "  shirt-sleeve  diplomacy  " ; 
by  some,  its  statements  have  been  regarded  as  unnecessarily  harsh  and 
stringent;  indeed,  the  question  has  been  raised  by  at  least  one  of  the 
schools  most  severely  criticized  whether  some  of  its  statements  might 
not  be  so  defamatory  as  to  give  grounds  for  legal  action  for  damage  to 
reputation.  But,  however  one  may  feel  as  to  the  relative  desirability 
or  success  of  the  method  of  persuasion  by  praising  the  best  and  the 
method  of  compulsion  by  brandishing  the  "big  stick,"  certain  it  is 
that  this  report  was  made  only  after  extensive  investigation  and  pro- 


TENDENCIES    IN    MEDICAL    EDUCATION  247 

longed  consideration  and  that  it  has  exerted,  in  the  brief  interval  since 
its  appearance,  an  immense  influence  for  good  on  the  faculties  of  medi- 
cal schools,  on  members  of  the  medical  profession  and,  through  the 
newspajjers,  on  the  general  public. 

Through  the  various  influences  above  mentioned  inferior  medical 
schools  are  rapidly  being  weeded  out  and  the  schools  left  are  steadily 
being  improved.  The  nation  has  set  itself  resolutely  to  the  task  of 
reconstruction  and  it  will  not  rest  satisfied  until  its  medical  schools 
have  reached  a  degree  of  efficiency  and  attained  to  a  power  of  public 
service  which  will  bear  favorable  comparison  with  similar  institutions 
anywhere  in  the  world. 

Position  of  and  Some  Tendencies  in  the  Non-clinical 

Departments 

On  examination  of  the  non-clinical  departments  of  the  better  medi- 
cal schools  in  the  United  States  it  will  be  seen  that  a  definite  policy 
has  been  established;  the  principles  of  this  policy  must  sooner  or  later 
be  observed  by  every  medical  school  which  hopes  that  its  conduct  may 
be  held  in  good  repute. 

The  Policy  Established 

The  essentials  of  the  policy  include:  (1)  commodious  laboratories 
equipped  with  all  modern  appliances  for  teaching  and  investigation  in 
anatomy,  physiology,  pharmacology,  biochemistry  and  pathology,  (2) 
"  full-time  "  professors  with,  for  the  more  part,  "  full-time  "  assistants, 
trained  or  undergoing  thorough  training  in  these  fundamental  disciplines, 
men  who  are  enthusiastic  teachers  and  have  a  zest  for,  and  success  in, 
prosecuting  original  inquiries,  and  (3)  an  annual  budget  at  the  dis- 
position of  the  staff  adequate  for  improvement  of  equipments,  for  sup- 
plies and  expenses  and  for  the  services  of  janitors,  clerks  and  mechanical 
assistants.  These  departments  are,  therefore,  not  only  places  in  which 
well-organized  courses  of  instruction  for  medical  students  are  offered; 
they  are  also  centers  in  which  knowledge  is  seethingly  advanced. 

Under  this  policy  the  non-clinical  departments  are  flourishing. 
Glance  throvxgh  "American  Men  of  Science"  and  make  lists  of  those 
who  have  been  led  to  cultivate  these  fields  and  have  been  notably  suc- 
cessful in  the  work.  You  find  an  imposing  array.  Look  over  the 
journals,  most  recently  founded,  devoted  to  the  different  subjects,  and 


248  MEDICAL   BE  SEARCH   AND   EDUCATION 

the  proceedings  of  the  scientific  societies,  and  you  will  be  gratified  to 
find  how  speedily  and  notably  knowledge  has  been  and  is  being  increased. 
The  best  American  work  is  receiving  adequate  foreign  recognition, 
and  while  but  few  European  students  have  thus  far  been  attracted  to 
American  non-clinical  laboratories  for  work,  the  stream  of  students 
which  formerly  flowed  in  the  other  direction  has  to  a  large  extent  ceased. 

Dangers  Threatening  the  Non-clinical  Departments 

The  non-clinical  chairs  in  the  medical  schools  may  be  to  a  certain 
extent,  however,  in  danger.  The  possibility  of  evil  has  arisen  not  at  all 
through  hostile  intention,  but  rather  through  certain  conditions,  partly 
external,  partly  internal,  which  may  place  them  in  a  trying  situation. 
Of  these  conditions  I  shall  refer  now  only  to  three,  viz.,  (1)  the  rise  of 
institutions  devoted  solely  to  research,  (2)  the  rapid  formation  of 
medical  faculties  in  state  universities,  and  (3)  the  pecuniary  penalty 
attaching  to  chairs  on  a  "university  basis." 

The  Rise  of  Institutes  for  Research 

In  both  Europe  and  America,  men  of  wealth  on  the  one  hand  and 
governmental  departments  on  the  other,  impatient  for  science  to  pro- 
gress, have  been  endowing  institutes  devoted  purely  to  investigation  in 
the  medical  sciences,  free  from  any  necessity  of  teaching.  The  Pasteur 
Institute  of  Paris  is  a  notable  example;  the  Institute  for  Infectious 
Diseases  and  the  Laboratory  of  the  Government  Health  Office  in  Berlin 
and  Ehrlich's  Institute  for  Experimental  Therapy  in  Frankfort-am- 
Main  are  German  instances;  in  the  United  States  may  be  mentioned 
the  laboratories  for  investigation  of  cancer,  the  government  laboratories 
for  medical  investigation  in  the  Army  and  in  the  Marine-Hospital  Ser- 
vice in  Washington,  The  Eockefeller  Institute  for  Medical  Research  in 
New  York,  the  Carnegie  Laboratory  for  the  Study  of  Nutrition  in 
Boston,  the  Memorial  Institute  for  Infectious  Diseases  in  Chicago,  the 
Sprague  Laboratory  for  Medical  Research  in  the  same  city,  the  Phipps 
Institute  for  Tuberculosis  in  Philadelphia,  the  Wistar  Institute  of 
Anatomy  in  the  same  city  and  the  Gushing  Laboratory  of  Experimental 
Medicine  in  Cleveland.  Such  research  institutions  give  unusual  facili- 
ties for  the  pursuit  of  original  inquiries;  by  virtue  of  this  fact  and 
of  their  large  endowments  they  permit  of  larger  rewards  in  the  way  of 
opportunity  for  work,  fame  and  salary  than  are  possible  in  ordinary 


TENDENCIES    IN    MEDICAL    EDUCATION  249 

university  positions.  As  a  result  able  and  distinguished  investigators 
who  otherwise  would  have  been  available  for  the  medical  faculties  cease 
to  be  accessible  to  them;  though  the  sciences  themselves  enjoy  enrich- 
ment— undoubtedly  these  institutions  are  fully  justifying  their  creation 
— the  strength  and  vitality  of  the  school-corps  is  correspondingly  de- 
pleted. When  possible,  such  research  institutions  should  be  placed 
contiguous  to  the  buildings  of  a  medical  school,  in  order  that  the  latter, 
even  if  separately  administered,  may  benefit  by  their  atmosphere.  What 
a  pity  that  the  universities  have  been  so  short-sighted  that  they  have 
not  foreseen  the  desirability  and  ultimate  necessity  of  a  division  of 
labor  in  the  non-clinical  departments  among  professors  whose  function 
is  predominantly  teaching,  and  professors  whose  function  is  predomi- 
nantly investigation! 

The  Large  and  Sudden  Demand  for  Professors 

The  second  condition,  the  rapid  formation  of  medical  faculties  in 
state  universities,  as  well  as  the  fusion  of  groups  of  schools  into  single 
stronger  schools,  has  created  a  demand  for  a  larger  number  of  so-called 
"whole-time,"  non-practitioner  professors  of  anatomy,  physiology, 
pathology,  etc.  This  demand  has  been  greater  than  could  be  supplied. 
Only  a  few  men  adequately  prepared  for  high  positions  have  been 
trained;  moreover,  in  many  of  the  institutions,  the  positions,  though 
high  in  rank,  are  still  low  in  facilities  and  salary.  In  time,  the  public 
will  become  sufficiently  educated  to  make  proper  provisions  in  the  state 
universities  for  equipment  and  salaries.  As  yet,  in  only  a  few  state 
institutions  can  it  be  said  that  this  has  been  done.  The  effect  likely  to 
be  produced  sooner  or  later  can  be  foreseen.  There  is  danger  that  the 
cradle  of  the  science  nurseries  will  be  robbed.  Many  lusty  infantss 
might,  despite  their  premature  parting  from  parental  props,  grow 
speedily  and  satisfactorily  to  adulthood,  leaping  as  it  were  over  adoles- 
cence, but  in  some  instances,  sureh'',  we  would  see  an  arrested  develop- 
ment. Thus,  through  the  exit  at  the  top  of  many  of  the  best  and 
through  the  entrance  at  the  bottom  of  too  many  immature  and  par- 
tially trained,  the  high  standards  thus  far  maintained  for  the  non- 
clinical chairs  run  some  risk  of  depreciation.  At  present,  positions, 
such  as  they  are,  can  be  obtained  too  easily;  the  period  of  training  is 
so  shortened  as  to  make  the  attainment  of  a  high  grade  of  scholarship 
difficult.     There  is  the  dangerous  possibility,  too,  of  promoting  to  full 


250  MEDICAL   BESEAECH   AND   EDUCATION 

professorship  men  of  mediocre  talent,  who,  in  a  longer  and  more 
exacting  discipline,  would  find  their  true  academic  level,  or  would 
gradually  be  weeded  out  in  a  competition  in  which  the  prizes  were 
larger  and  the  number  of  intellectually  superior  contestants  more 
extended. 

The  Financial  Status  of  the  Professor 

And,  thirdly,  perhaps  even  a  graver  matter,  because  it  affects  not 
only  the  occupants  of  the  non-clinical  chairs  of  the  medical  faculties, 
but  those  of  the  chairs  in  the  colleges  of  liberal  arts  as  well,  is  the 
financial  status  of  the  professor  in  the  United  States.  This  important 
question  has,  as  far  as  colleges  and  universities  in  general  are  con- 
cerned, been  made  a  topic  of  especial  study  by  the  Carnegie  Founda- 
tion for  the  Advancement  of  Teaching,  and  the  results  of  the  study 
have  been  published  in  its  Bulletin  II.  (1908).  In  100  leading  colleges 
of  the  United  States  and  Canada  the  average  salary  of  the  full  pro- 
fessors varies  from  $1,350  to  $4,500,  the  average  of  all  being  about 
$2,500  per  year.  There  are  no  large  financial  prizes  that  can  be  looked 
forward  to  anywhere,  the  maximum  salary  being  $7,000  or  $8,000,  and 
only  a  very  few  places  yield  this.  If  larger  salaries  were  given  anywhere, 
even  though  the  chairs  enjoying  them  were  few,  the  larger  material 
potentialities  of  the  professor's  calling  might  exert  a  favorable  influence. 
There  are  thirty-five  institutions  known  as  colleges  in  which  the  average 
salary  for  full  professors  is  less  than  $500  per  year.  The  average  salary 
for  full  professors  in  the  Johns  Hopkins  University  is  stated  to  be 
$3,184. 

Of  course  in  professional  and  in  engineering  schools  the  professors' 
salaries  are  somewhat  higher  than  in  the  arts  departments.  But  the 
maximum  salary  for  a  non-clinical  chair  of  a  medical  department, 
except  possibly  in  New  York  City,  is,  as  far  as  I  know,  $5,000.  The 
average  salary  in  the  twenty  best  medical  schools  would  doubtless  fall 
far  below  this  level.  It  is  to  be  remembered,  of  course,  that  a  $3,000 
salary  in  Ann  Arbor  will  go  perhaps  as  far  as,  or  farther  than,  a  $5,000 
salary  in  Chicago.  The  occupants  of  non-clinical  chairs  like  those  of  the 
chairs  in  the  arts  departments  have  little  means  of  supplementing  their 
salaries  by  outside  work.  Some  of  them  do  executive  work  which  yields 
small  additional  emoluments;  some  write  text-books  which,  if  success- 
ful, bring  in  a  modest  amount  in  royalties;  now  and  then  a  professor 
receives  extra  pay  as  a  member  of  a  federal,  state  or  municipal  com- 


TENDENCIES    IN    MEDICAL    EDUCATION  251 

mission  of  experts.  There  is  no  income,  or  very  little,  from  consulta- 
tion practise,  for  anatomists,  physiologists  and  pathologists  have  but 
rarely  had  the  clinical  training  necessary  to  make  them  expert  diag- 
nosticians and  therapeutists;  moreover  a  code  of  ethics  has  gradually 
developed  which  goes  far  to  prevent  such  professors  from  engaging  in 
the  practise  of  medicine,  except  possibly  a  limited  consultation  work, 
even  when  their  experience  has  been  such  as  to  make  them  equal  to  it. 
The  feeling  prevails  that  such  outside  work,  so  different  from  that  of 
his  regular  activities,  lessens  a  professor's  opportunities  for  scholarly 
study  by  its  encroachment  on  his  time  and  energies  and  detracts  from 
the  dignity,  simplicity  and  high-mindedness  of  the  teacher's  calling. 
There  are,  of  course,  as  the  investigators  of  the  Carnegie  Foundation 
point  out,  a  few  men,  of  unusual  energy  or  endowed  with  especial  finan- 
cial sagacity  and  initiative,  who  will  easily  supplement  their  regular 
incomes,  no  matter  what  profession  or  business  they  may  be  engaged 
in,  but  men  of  this  kind  are  rare  and  it  is  probably  not  common  to 
find  the  type  especially  attracted  by  the  love  of  abstract  studies,  the 
quiet  of  the  scholar's  life  or  the  particular  sense  of  power  over  youth 
which  is  characteristic  of  the  feeling  of  a  great  teacher. 

That  some  great  teachers  and  investigators  are  attracted  to  the  non- 
clinical chairs  despite  the  small  material  rewards  and  the  heavy  finan- 
cial and  social  penalties  pertaining  to  the  positions,  has  been  fully 
demonstrated ;  that  some  will  continue  so  to  be  attracted  we  can  be  sure. 
Men  who  inordinately  love  gain  and  material  advancement  are  not 
likely  to  work  toward  professorships ;  it  is  perhaps  well  that  the  pro- 
fessorial class  is  recruited  elsewhere.  The  power  of  distinterested  scien- 
tific creation  and  the  passion  for  truth  and  research  are  seldom  cere- 
brally  compatible  with  the  money-getting  gift,  the  capacity  to  devote 
one's  self  to,  and  to  keep  the  mind  concentrated  on,  financial  gain.  The 
life  of  a  professor  is  necessarily  simple  and  frugal;  his  wife  can  make 
no  pretense  to  the  absurd  and  vulgar  extravagance  that  Irving  Bacheller 
facetiously  and  satirically  describes  as  "keeping  up  with  Lizzie."  The 
career  of  a  professor  is  often,  however,  one  of  profound  influence  and  of 
steady  happiness,  of  high  honor  and  well-deserved  respect,  and  these  are 
rewards  not  likely  to  be  regarded  lightly  among  the  more  idealistic  of 
our  youth. 

Still,  it  must  frankly  and  anxiously  be  admitted  that  there  are  ele- 
ments in  the  financial  status  of  non-clinical  professors  which  make  us 


252  MEDICAL   SESEABCH   AND   EDUCATION 

stand  in  pause  when  we  think  intently  on  the  situation.  Ko  matter  how 
keen  the  love  of  teaching,  how  hearty  the  satisfaction  in  solving  scien- 
tific problems,  a  strong  man  can  scarcely  be  expected  to  devote  himself 
to  a  life  of  instruction  and  research  when  the  remuneration  is  inade- 
quate to  the  real  needs  of  himself  and  his  family  during  his  period  of 
activity,  and  to  provision  for  his  old  age. 

It  is  highly  desirable  that  the  compensation  of  professors  should  be 
a  little  above  rather  than  below  the  line  of  comfort  for  the  locality  in 
which  they  live.  It  should  be,  at  least,  large  enough  to  furnish  the 
necessaries  and  conveniences  of  life,  without  superfluity,  and  should  not 
be  so  small  as  to  prevent  a  man  from  saving  each  year  a  part  of  his 
receipts,  even  though  a  smaller  fraction  of  them  than  Bacon  recommends. 
The  struggle  to  live,  financial  worries,  inability  to  educate  the  children 
of  the  family,  too  great  personal  hardship,  and  the  social  penalties  of 
too  small  an  income  are  sure  more  or  less  to  inhibit  a  man  in  his  work. 

This  danger  of  insufficient  income  for  the  non-clinical  professor  is 
no  bugaboo  born  of  my  fancy;  there  is  more  than  one  institution  in 
which  instances  may  easily  be  made  of  perception  and  not  of  mere 
ideation. 

The  material  rewards  of  professorships  can  not,  it  is  true,  be 
expected  to  become  equal  to  those  of  industrial  life.  It  must  be  kept  in 
mind,  however,  that  the  full  professors  in  universities  are  the  men  of 
greatest  success  in  their  class :  if  the  salaries  of  such  men  fall  below  the 
line  of  comfort  the  character  of  the  whole  class  is  endangered  and  the 
student  body  and  society  as  a  whole  must  ultimately  suffer.  Unless 
some  method  can  be  found  for  improving  the  financial  position  of  the 
university  professor  it  is  to  be  feared  that  many  men  who  otherwise 
would  shed  luster  on  scholarship  will,  sadly  citing  the  well-known 
phrase  from  Horace,  virtus  post  nummos,  be  driven  away  from  scientific 
medicine  to  enter  other  pursuits.  Society  ought  not  financially  so  to 
penalize  the  professorial  class  that  the  occupancy  of  chairs  by  the 
stronger  personalities  will  be  limited  to  bachelors,  to  childless  men,  to 
men  enriched  through  the  accidents  of  inheritance  or  marriage,  or  to 
married  men  who  consent  to  doom  their  wives  and  children  to  the  miti- 
gated happiness  which  poverty  affords. 

Men  of  some  sort  there  will  naturally  be  who  will  seek  salaried  posi- 
tions, no  matter  how  low  the  salary,  and,  fortunately,  the  love  of  teach- 
ing, of  study  and  investigation  will  always  secure  a  certain  number  of 


TENDENCIES    IN    MEDICAL    EDUCATION  253 

gifted  men  whose  passion  will  make  them  work  at  the  thing  they  like 
under  any  conditions.  But  if  the  fiscal  arrangements  of  professorships 
were  to  be  made  in  such  a  way  that  they  attracted  chiefly  mediocre 
persons  to  whom  a  salaried  position  spells  security,  the  higher  interests 
of  scholarship  would  suffer.  Attention  need  scarcely  be  directed  to  the 
progressive  declension  of  our  public  schools  through  precisely  this  en- 
forced withdrawal  of  their  able  men. 

The  interest  in,  and  joy  of,  work,  the  desire  of  public  service,  the 
anxiety  to  do  something  well,  the  longing  for  the  good  opinion  of  one's 
colleagues,  the  obtaining  of  leisure  to  devote  one's  self  to  the  finer 
interests  of  life — these  must  always  be  the  great  motives  which  lead 
men  to  become  university  professors.  The  material  rewards  are  not, 
however,  wholly  insignificant.  On  psychological  grounds,  I  have  always 
felt  that  there  should  be  some  way  in  which  all  the  rewards  of  each 
individual  might  be  improved  by  an  increase  in  the  quality  and  quantity 
of  his  effort.  It  is  by  no  means  necessary  that  the  increment  stand  in 
any  proportional  relation  to  the  work  done;  men  and  women  good 
enough  to  be  professors  will  work  honestly  and  loyally  at  the  thing 
they  want  to  do  without  any  continually  conscious  idea  of  personal  bene- 
fit. But  there  come  periods  in  the  life  of  each  one  of  us  when  the  main- 
tenance of  our  higher  standards  is  difficult,  when  we  are  tempted  to  be 
slothful  or  distraught;  at  such  times,  unless  we  are  really  ill  and  need 
rest  or  change,  the  more  stimuli  there  are  to  exertion  the  better,  even 
though  some  of  them  influence  what  are  regarded  as  the  less  noble  parts 
of  our  natures. 

In  salaried  establishments,  again,  it  is  not  always  possible  to  avoid 
the  defects  of  "  institutionalism  " — bureaucratic  officialdom,  the  tyran- 
nies of  a  mandarinate  and  oligarchic  indolence ;  those  interested  in  the 
organization  of  asylums  for  the  insane  have  repeatedly  lamented  this 
fact. 

It  is  easy  to  point  out  the  dangers,  but  hard  to  see  how  to  obviate 
them;  possibly  the  creation  of  a  certain  number  of  large  prizes  might 
have  the  desired  effect.  In  Germany,  teaching  is  stimulated  by  the  sys- 
tem which  gives  every  professor  a  small  additional  fee  for  each  student 
whom  he  attracts  (CoUegiengelder),  but  this  system  has  its  drawbacks 
and,  moreover,  could  scarcely  be  applied  in  the  United  States,  where  as 
yet  universities  are  not  a  chain  of  government  institutions  under 
federal  control,  and  where  students  do  not  migrate.     The  education  of 


254  MEDICAL   BE  SEARCH   AND    EDUCATION 

public  opinion  to  greater  social  recognition  of  the  professorial  class 
might  help;  it  progresses  rather  slowly  in  a  country  in  which  "suc- 
cess" is  largely,  as  yet,  measured  by  income;  those  who  have  not 
learned  how  to  get  money  and  to  keep  it  are  too  often,  by  the  un- 
thinking, indiscriminately  classified,  not  quite,  perhaps,  as  pariahs,  cut 
off  socially  from  hope,  but  still  as  futile  persons,  too  innocent  for 
"  achievement "  in  a  land  of  opportunities  ! 

An  especially  pressing  factor  during  recent  years  has  been  the 
gradual  rise  in  the  cost  of  living  without  any  proportionate  increase 
in  the  salaries  of  university  professors.  The  average  price  of  commod- 
ities has  increased  by  33  per  cent,  to  50  per  cent.,  but  the  professor 
who  was  paid  $2,000  or  $5,000  before  this  rise  took  place  is  still  com- 
pelled to  live  on  the  same  amount.  The  trustees  of  universities  may 
sometimes  be  provided  with  endowments  which  will  permit  them  auto- 
matically to  raise  or  lower  the  amounts  of  professors'  salaries  parallel 
with  the  changes  taking  place  in  the  cost  of  living. 

The  system  of  retiring  allowances  for  professors,  instituted  by  the 
Carnegie  Foundation  for  the  Advancement  of  Teaching,  will  un- 
doubtedly do  much  to  improve  the  economic  position  of  the  university 
professor.  Some  system  which  will  permit,  also,  of  insurance  against 
death  or  disability  preceding  the  age  of  retirement  ought  to  be  devised. 
The  extinction  of  superfluous  colleges  with  corresponding  reduction  in 
the  number  of  professorships  may  lead  gradually  to  an  increase  in  the 
honoraria  pertaining  to  the  chairs  that  remain.  The  whole  situation 
should  certainly  be  canvassed  carefully  and  the  means  discovered  for 
enhancing  in  various  ways  the  social  and  pecuniary  rewards  of  pro- 
fessors in  the  non-clinical  branches  of  our  medical  schools. 

Position  of  and  Tendencies  in  the  Clinical  Dfpaktments 
The  policies  followed  in  the  clinical  departments  of  the  better  uni- 
versity schools  are  far  from  uniform.  There  is,  as  yet,  no  unanimity  of 
opinion  as  to  the  best  way  to  improve  these  departments.  All  are 
agreed  as  to  certain  fundamental  'points:  the  desirability  (1)  of  more 
thorough  practical  teaching  and  (2)  of  an  increase  in  scientific  pro- 
ductivity. How  best  to  move  toward  the  practical  realization  of  these 
ideals  is  a  question. 

A  State  of  Flux 
The  clinical  departments   of  the  medical  schools   of  the  United 
States  are  on  the  eve,  it  would  seem,  of  important  reforms.     To  bring 


TENDENCIES    IN    MEDICAL    EDUCATION  255 

them  about,  radical  changes  may  be  necessary.  Faculties  will,  doubt- 
less, be  led  to  experiment  in  various  ways;  only  after  trials  through  a 
considerable  period  shall  we  be  able  to  decide  on  the  arrangements  and 
organization  suitable  for  general  adoption  in  the  better  schools.  A 
state  of  flux,  already  evident  in  the  clinical  departments,  is,  therefore, 
likely  to  continue  and  to  become  even  more  pronounced  during  the 
next  decade. 

In  medicine,  which  is,  and  must  always  be,  the  department  of  pri- 
macy in  a  medical  school,  and  also  in  surgery,  the  tendency  to  fill 
chairs  by  attracting  able  men  from  a  distance  has  finally  begun.  It  was 
formerly  impossible  on  account  of  the  absence  of  school-controlled  hos- 
pitals. The  medical  faculties  were  compelled  to  accept  as  their  clinical 
professors  men  who,  developing  locally,  were  the  physicians  to  muni- 
cipal or  to  privately  endowed  hospitals.  In  no  other  way  could  "  clinical 
material"  for  the  instruction  of  students  be  obtained.  !N"ow  that  uni- 
versities are  beginning  to  have  their  own  hospitals,  or  to  enter  into 
arrangements  with  other  hospitals  through  which  their  professors  are 
assured  directing  places  on  the  hospital  staff,  professors  may  be  called 
from  a  distance,  or  be  selected  from  the  local  profession,  on  account  of 
their  skill  in  diagnosis  and  therapy,  their  ability  as  teachers  and  their 
power  as  original  investigators. 

The  Principal  Clinical  Chairs  and  the  Specialties 

The  three  principal  clinical  chairs  in  a  medical  school  must  always 
be  those  of  medicine,  surgery  and  obstetrics.  A  general  training  in  each 
of  these  branches  is  absolutely  essential  in  the  education  of  every 
medical  student. 

In  the  specialties,  there  is  time,  in  the  brief  period  of  the  clinical 
curriculum,  to  teach  the  student  only  the  most  salient  methods  of 
diagnosis  and  treatment,  those  suited  to  the  needs  of  the  general  prac- 
titioner. Except  for  brief  courses  in  ophthalmology,  psychiatry  and, 
possibly,  pediatrics,  it  is  doubtful  whether,  in  the  time  at  present 
allotted  to  clinical  instruction,  it  is  justifiable  to  make  obligatory  any 
training  in  the  clinical  specialties  beyond  that  which  can  be  given  in 
the  departments  of  medicine,  surgery  and  obstetrics.  There  are  three 
reasons  for  the  view  here  advanced.  In  the  first  place,  medical  schools 
are  as  yet,  in  this  country,  devoid  of  the  endowments  necessary  for  the 
equipping  and  manning  of  university  departments  in  the  specialties  like 


256  MEDICAL   BESEABCE   AND   EDUCATION 

gynecology,  genito-urinary  diseases,  orthopedics,  neurology,  ear,  nose 
and  throat,  dermatology,  gastro-enterology,  etc.  In  the  second  place, 
courses  given  to  undergraduate  students  in  such  departments,  could 
they  be  established,  would  have  to  be  rigidly  restricted  to  essentials  if 
each  subject  were  to  occupy,  in  the  curriculum,  its  true  position  of 
relative  value  to  the  student.  A  specialist,  naturally  and  properly 
impressed  with  the  importance  of  his  own  subject,  tends  to  enlarge  on 
it  and  to  inflate  it  out  of  all  proportion  to  its  legitimate  position  in  the 
undergraduate  medical  curriculum.  The  right  place  for  extended 
courses  in  the  specialties  is  in  the  postgraduate  medical  school  in 
which  men  equip  themselves  for  special  practise.  And,  in  the  third 
place,  it  is  important  that  teachers  in  the  general  departments  of 
medicine  and  surgery  be  able  to  diagnose  all  ordinary  conditions  and 
to  treat  the  simpler  and  commoner  affections,  no  matter  to  what  special 
branch  they  belong,  just  as  the  family  practitioner  has  to  do.  What  a 
bad  impression  it  must  make  on  a  student  in  the  medical  wards  if  his 
professor  of  medicine,  when  a  patient  complained  of  cough  or  of 
hoarseness,  was  unable  to  make  a  larynoscopic  examination,  but  had  to 
refer  the  patient  to  the  specialist  in  the  "throat  and  chest"  clinic;  or 
if,  when  the  patient  had  indigestion,  he  were  referred  to  the  "  stomach 
clinic,"  or  in  the  case  of  palpitation  to  the  "  heart  clinic  " !  And  how 
discouraging  it  would  be  also  to  the  student  in  the  surgical  wards  if  his 
professor  of  surgery  felt  himself  incapable  of  examining  the  prostate, 
of  recognizing  a  flat  foot,  of  detecting  the  presence  of  a  pus  tube  or  of 
diagnosticating  a  simple  eczema.  The  continual  reference  of  such  cases 
to  other  departments  without  at  least  preliminary  study  by  the  teachers 
of  general  medicine  and  surgery  would  imply  such  a  disintegration  of 
medical  thought  as  to  have  a  very  bad  influence  on  the  students.  The 
tendency  would  be  for  them  to  grow  accustomed  to  the  idea  that  it  was 
not  necessary  for  them  to  examine  every  patient  thoroughly  or  to  treat 
him.  "If  the  professor  of  medicine  or  surgery  in  a  great  medical 
school  is  unable  to  differentiate  the  simpler  and  more  common  condi- 
tions in  the  special  branches,  how  can  we  be  expected  to  do  so  when  we 
go  out  into  practise  for  ourselves?"  is  a  question  these  students  would 
ask  themselves. 

The  picture  of  medical  practise  as  seen  in  the  six  great  branches — 
medicine,  surgery,  obstetrics,  ophthalmology,  psychiatry  and  pediatrics 
— is  already  so  intricate  that  it  would  be  unfortunate  if  students  in  the 


TENDENCIES    IN    MEDICAL    EDUCATION  257 

medical  schools  were  compelled  still  further  to  complicate  it.  Moreover, 
a  medical  clinic  in  which  the  larynx  was  not  inspected,  the  eye-grounds 
not  looked  at,  the  stomach  not  examined,  the  heart  not  auscultated,  or 
in  which  electric  and  various  laboratory  examinations  were  not  made, 
would  be  a  caricature  of  a  medical  clinic.  Each  assistant  in  our  great 
clinics,  though  especially  skilled  in  the  technic  of  his  own  branch,  should 
command  all  the  ordinary  methods  of  examination  which  the  general 
practitioner  may  be  expected  to  employ.  The  student  should  be  im- 
pressed with  the  fact  that  there  is  no  "  witchcraft "  about  the  technic 
of  these  methods,  that  it  can  be  acquired  by  practise  and  routine  and 
that  it  must  be  so  acquired.  Billroth  long  ago  called  attention  to  these 
points  and  urged  that,  if  all  the  special  methods  of  investigation  were 
shoved  out  of  the  major  clinics  into  special  courses,  not  an  integral  part 
of  them,  and,  especially,  if,  in  such  special  courses,  the  technical  side 
were  so  expanded  as  to  become  disproportionate,  sight  would  be  lost  of 
the  relative  significance  of  each  specialty  in  the  study  of  the  body  as  a 
whole  and  the  students  in  the  medical  school,  through  the  extreme  dis- 
integration and  the  lack  of  cohesion,  would  become  completely  dis- 
couraged. 

For  the  postgraduate  work  of  the  university  medical  school,  the 
special  clinics  are  highly  desirable.  In  them  the  special  subjects  ought 
to  be  advanced  by  original  investigation;  there,  too,  physicians  should 
be  able  to  prepare  themselves  for  special  practise.  Where  the  material 
is  rich,  and  especially  when  the  man  directing  a  special  clinic  is  intel- 
lectually able  and  possesses  creative  power,  a  reputation  could  soon  be 
gained  which  would  attract  postgraduate  students  from  different  parts 
of  the  civilized  world;  such  a  special  clinic  would  lend  brilliancy  and 
prestige  to  the  university  which  provided  for  it.  But,  while  arranging 
liberally  for  scientific  and  investigative  work  in  all  the  general  and 
special  clinics,  great  care  should  be  taken  to  see  that  this  is  not  done  at 
the  cost  of  the  undergraduate  instruction. 

The  Hospitals  of  the  Medical  Schools  and  Their  Management 

The  most  pressing  need  in  the  clinical  departments  of  the  medical 
schools  of  the  United  States,  at  present,  is  that  of  school-controlled 
hospitals  in  which  the  students  may  actively  participate  in  the  work  of 
diagnosis  and  treatment  and,  under  skilled  direction,  be  held  respon- 
sible therefor.     In  the  hospitals,  the  conditions  should  permit  of  an 

18 


258  MEDICAL   EESEAECH   AND    EDUCATION 

adequate  organization  for  the  three  great  functions  of  a  university  clinic 
— practise,  teaching  and  research.  These  hospitals  should  be  large 
enough  to  supply  sufficient  clinical  material  in  internal  medicine,  sur- 
gery, obstetrics  and  in  the  principal  specialties.  The  organization  should 
ensure  a  large  degree  of  departmental  autonomy  while  providing  for 
proper  correlation  of  the  activities  of  all  the  clinics. 

It  is  only  here  and  there  in  the  United  States  that  one  finds  belong- 
ing to  a  medical  school  (1)  a  hospital  of  sufficient  size,  equipped  with 
teaching  and  working  quarters,  with  wards  situated  in  immediate  con- 
tact with  commodious  clinical  laboratories,  (2)  an  organization  accord- 
ing to  which  the  professors  of  the  clinical  departments  of  the  medical 
faculty  are  also  the  principal  physicians  and  surgeons  on  the  hospital 
staff,  the  whole  control  of  the  individual  departments  being  in  the  hands 
of  the  respective  professors.  Until  medical  faculties  obtain  by  endow- 
ment or  agreement  facilities  of  this  sort,  the  clinical  sciences  must 
remain  backward  in  their  development. 

There  is,  probably,  not  a  single  institution  in  the  United  States 
which  has,  as  yet,  a  wholly  satisfactory  arrangement  between  the 
medical  school  and  the  hospital  in  which  the  clinical  work  is  done. 
Even  in  some  of  the  institutions  pointed  to  as  paradigms  of  an  ideal 
relationship  the  conditions  are,  in  reality,  far  from  ideal.  Unless  the 
medical  school  and  the  hospital  are  actually  integral  parts  of  a  single 
corporation  it  is  hard  to  devise  an  organization  which  will  prevent 
friction;  for,  in  the  present  undermanned  clinics,  the  hospital,  on  the 
one  hand,  is  often  found  maintaining  that  the  staff  is  paying  too  much 
attention  to  instruction  and  to  research,  to  students  and  to  laboratories, 
and  not  enough  to  the  interests  of  the  patients  themselves,  while  the 
medical  school  is  constantly  urging  that  the  routine  work  of  the  care  of 
patients  in  the  hospital  is  not  university  work,  that  those  devoting 
themselves  to  it  are  not  worthy  of  university  recognition,  or  that  they 
are  too  much  interested  in  caring  for  the  patients  and  not  sufficiently 
devoted  to  teaching  and  the  solving  of  those  problems  in  diagnosis  and 
therapy  which  the  study  of  the  patients  should  suggest.  Where  the 
finances  of  the  hospital  are  kept  separate  from  the  finances  of  the  medi- 
cal school  there  are  often  disputes  as  to  the  portion  of  the  expense  in 
the  clinic  to  be  borne  by  the  hospital  on  one  side  and  by  the  medical 
school  on  the  other,  and  even  M^hen,  after  conference,  a  theoretically 
satisfactory  understanding   as   to   the   division   of   expense   has   been 


TENDENCIES    IN    MEDICAL    EDUCATION  259 

arrived  at,  one  finds,  in  actual  experience,  a  persistence  of  the  friction. 
In  my  opinion  this  vexatious  state  owes  its  origin  (1)  to  the  separate 
developments  in  this  country  of  the  hospitals  and  the  medical  schools, 
(2)  to  the  imperfect  fusions  which  have  come  later  on,  leaving  authority 
still  somewhat  divided,  (3)  to  the  immense  amount  of  work  to  be  done 
and  the  insufficient  number  of  people  to  do  it,  and  (4)  especially,  to  a 
misunderstanding  both  by  hospital  officials  and  by  university  authori- 
ties of  the  value  and  dignity  of  the  different  portions  of  the  work  which 
must  be  carried  on  in  the  clinics.  In  reality,  the  interests  of  the  hos- 
pital and  of  the  medical  school  are  one  when  the  functions  of  the  clinics 
are  properly  understood,  organized  and  administered;  there  should  be 
no  more  quarrel  between  hospital  and  medical  school  than  between 
unselfishness  and  the  higher  selfishness.  But  as  long  as  there  is  a  divi- 
sion of  responsibility  and  control,  ideal  conditions  in  the  clinic  will 
rarely,  if  ever,  be  reached. 

Another  serious  defect  in  the  hospitals  as  they  are  now  lies  in  their 
management  as  general  hospitals  under  an  executive  head,  rather  than 
as  separate,  largely  autonomous  clinics,  the  activities  of  which  are  cor- 
related by  a  committee  made  up  of  representatives  of  the  individual 
clinics  in  association  with  a  general  executive  head.  Until  we  have,  as 
in  the  German  hospitals  and  m.edical  schools,  (1)  a  medical  clinic,  (2) 
a  surgical  clinic,  (3)  an  obstetrical  clinic  or  a  woman's  clinic,  and  (4) 
the  various  special  clinics — each  organized  as  a  separate  entity,  with  its 
own  staff,  preferably  with  its  own  buildings,  certainly  with  its  own 
budget,  with  control  vested  in  the  department  itself — the  conditions 
under  which  work  is  done  will  continue  to  be  unsatisfactory.  Unless 
the  department  of  surgery,  for  example,  can  admit  and  discharge 
patients  at  will,  can  decide  on  the  kind  of  work  it  will  do,  can  buy- 
instruments,  books,  etc.,  whenever  needed  as  long  as  the  budget  of  the 
clinic  is  not  exceeded,  surgery  and  surgical  investigation  will  be 
hampered.  When  these  matters,  for  all  the  clinics,  lie  within  the 
province  of  an  extra-departmental  authority  there  are  apt  to  be  unneces- 
sary delays,  arbitrary  decisions  and  other  obstructive  measures  which 
are  irritating  and  inhibiting  to  work. 

These  difficulties  are  pointed  out  without  any  intention  of  unfairly 
criticizing  executive  officers  in  our  large  general  hospitals.  Among 
hospital  superintendents  there  are  many  men  of  unusual  executive 
ability  and  of  high  ideals;  they  have  often  cooperated  harmoniously 


260  MEDICAL   BESEAECH   AND   EDUCATION 

with  those  who  have  the  interests  of  the  medical  school  at  heart.  My 
comments  refer  merely  to  the  faults  inherent  in  a  system ;  the  positions, 
as  at  present  constituted,  certainly  have  in  them  factors  which  do  not 
make  for  the  best  interests  either  of  hospital  or  of  medical  school.  One 
of  the  problems  to  be  worked  out,  then,  in  our  university  hospitals, 
consists  in  articulating  satisfactorily  the  general  administrative  work  of 
the  institution  with  the  special  administrative  work  of  the  individual 
clinics;  in  other  words,  we  must  find  out  how  those  who  examine 
patients  and  treat  them,  those  who  instruct  students  and  those  who 
make  original  investigations,  can  be  relieved  of  general  administrative 
difficulties,  on  the  one  hand,  and  favored  in  their  special  departmental 
functions,  on  the  other. 

Of  course,  it  should  be  admitted  frankly  that,  in  the  present  system, 
general  superintendents  of  hospitals  often  find  departmental  professors 
difficult.  Not  every  professor  of  medicine  or  surgery  is  a  good  business 
man  or  has  administrative  skill;  indeed  it  is  not  uncommon  to  find 
men  strong  as  investigators,  teachers  or  practitioners,  but  somewhat 
lacking  in  business  sagacity  and  executive  ability;  occasionally  when 
gathered,  grumbling  and  querulous,  in  a  superintendent's  office,  they 
convert  it  into  a  veritable  cave  of  Adullam !  In  particular  instances 
provision  might  be  made  to  free  a  professor  as^  much  as  possible  from 
.administrative  work.  It  could  be  easily  carried  on  for  him  by  another 
member  of  the  department,  or  by  a  chief  clerk  who  might  be  a  non- 
medical man.  The  ultimate  solution  of  this  difficult  problem  may  lie 
in  the  appointment  of  a  salaried  executive  clerk  in  each  of  the  clinical 
departments  to  look  after  administrative  matters,  the  work  of  all  such 
officers  to  be  supervised  and  correlated  by  a  general  business  superin- 
tendent who  would  be  responsible  to  the  medical  board  of  the  hospital. 

Departments  of  Internal  Medicine 

The  functions  of  each  of  the  clinical  departments  are  manifold  and 
complex.  Let  me  refer  to  some  of  the  activities  of  the  branch  about 
which  I  know  most;  namely,  internal  medicine.  If  one  attempt  to 
resolve  the  functional  complexity  of  that  branch  into  its  component 
aspects  one  can  distinguish,  at  once,  at  least  four  principal  parts : 

1.  The  practise  of  medicine  in  the  public  and  private  wards  and  in 
the  out-patient  department  and  the  laboratories  thereto  pertaining,  by 
which  I  mean  the  actual  diagnosis  and  treatment  of  disease  in  the 
patients  who  enter  the  clinic. 


TENDENCIES    IN    MEDICAL    EDUCATION  261 

2.  The  teaching  in  the  wards,  in  the  dispensaries  and  in  the  labora- 
tories of  {a)  undergraduate  medical  students;  (&)  assistants  and 
associates;  (c)  physicians  taking  postgraduate  courses  in  the  depart- 
ment. 

3.  The  prosecution,  by  professors,  assistants  and  postgraduate  stu- 
dents, of  original  inquiries  in  internal  medicine,  the  search  for  new 
methods  of  diagnosing  and  treating  disease,  the  attempt  to  advance 
our  knowledge  of  the  subject  beyond  its  present  boundaries. 

4.  The  administrative  duties,  including  the  admission,  transfer  and 
discharge  of  patients,  interviews  and  correspondence  with  phj^sicians 
who  bring  patients,  and  with  the  relatives  and  friends  of  the  sick,  the 
relations  of  the  clinic  to  housekeeping  and  nursing,  the  maintenance 
of  records  and  statistics,  the  arrangements  for  publications,  the  super- 
intendence of  budgets  and  expenditures,  the  making  of  appointments 
and  promotions,  the  attendance  on  departmental  and  inter-departmental 
conferences,  the  formulation  of  curricula,  the  organization,  equipment 
and  running  of  the  several  clinical  laboratories,  the  library,  and  the 
museum,  the  integration  of  departmental  activities,  the  development  of 
an  esprit  de  corps^  etc. 

The  Practise  of  Medicine  in  the  Clinic 

Turning  now  to  a  little  closer  examination  of  the  work  of  the  medi- 
cal clinic  of  a  modern  school  and  hospital  it  will  be  found  that  the  prac- 
tise of  medicine  in  the  clinic  itself  is,  separately  considered,  no  small 
task.  In  order  that  the  teachers  and  investigators  in  the  clinic  may  be 
sure  of  getting  what  they  need,  or  prefer,  in  their  work,  a  large  number 
of  cases  from  which  to  select  must  be  admitted  to  the  hospital.  The 
larger  the  clinical  material  available  the  better.  The  time  may  come 
when,  in  addition  to  the  general  reception  wards  of  the  stationary  clinic, 
there  will  be  special  wards  to  which  may  be  transferred  the  cases  most 
suitable  for  teaching,  on  the  one  hand,  and  for  investigation  on  the 
other.  The  larger  reservoir  for  the  reception  of  the  cases  previous  to 
selection  will  always  be  necessary,  for  in  the  first  place,  until  a  patient 
has  been  fairly  well  studied,  one  can  not  be  sure  how  valuable  he  may 
be  for  illustration  in  teaching  or  for  the  suggestion  of  problems  for 
original  scientific  investigation;  in  the  second  place,  every  great  hos- 
pital must,  on  humanitarian  grounds,  take  in  many  cases  which,  at  the 
time,  may  be  of  relatively  little  educational  or  scientific  interest. 


262  MEDICAL   RESEABCH   AND    EDUCATION 

A  large  department  for  out-patients,  a  so-called  "policlinic"  or 
" ambulatorium/'  is  also  necessary  for  three  reasons:  first,  on  humani- 
tarian grounds,  to  provide  treatment  for  the  poor  who,  though  not  well, 
are  not  so  sick  as  to  require  admission  to  the  wards  of  the  hospital; 
again,  as  a  feeder  to  the  stationary  clinic,  to  which  can  be  sent  the 
sicker  patients,  those  exemplifying  unusually  well  the  pathological 
states  under  consideration  at  the  time  in  the  educational  work  in  the 
wards,  and  those  presenting  obscure  conditions,  necessitating  for  diag- 
nosis more  elaborate  studies  than  are  feasible  in  the  policlinic;  and 
finally,  for  teaching  purposes  in  the  policlinic  itself,  for  here  material 
of  a  special  kind  becomes  available  for  the  teaching  of  students,  includ- 
ing not  only  slightly  ill  patients  suitable  for  the  practical  courses  in 
physical  diagnosis  and  other  propaedeutic  studies,  but  also  precisely  the 
types  of  minor  ailments  which  the  young  physician  is  most  likely  to 
meet  when  he  starts  out  in  practise.  The  ills  of  the  ambulatory  patients, 
though  sometimes  permitting  continuance  of  occupation,  require  regular 
supervision.  Chronic  diseases  of  the  heart  and  blood-vessels,  of  the 
kidneys,  of  the  liver  and  lungs,  perhaps  prevail.  Functional  nervous 
cases  are  also  frequently  seen.  The  student  has  the  opportunity  of 
inquiring  into  the  personal  history  and  social  relationships  of  such 
patients,  to  investigate  the  bearing  of  obscure  organic  disease  on 
psychoneurotic  states  and  to  see  in  how  far  they  may  be  influenced  by 
psychotherapeutic  and  other  remedial  measures.  In  connection  with 
the  social  service  department,  the  personal  relations  and  experiences  of 
these  patients  can  be  investigated  and,  sometimes,  disentangled. 
Organic  nervous  cases  (tabes,  multiple  sclerosis,  etc.)  can  also  be  studied 
here  to  advantage,  since  but  few  hospitals  have  as  yet  provided  special 
neurological  wards,  and  where  they  have  been  provided  they  can  take 
care  of  but  a  fraction  of  the  material  which  offers. 

In  addition  to  the  public  wards  and  the  policlinic,  most  univer- 
sity hospitals  have,  and  all  should  have,  private  rooms  in  which 
pay  patients  may  be  received.  In  them  well-to-do  people  may  avail 
themselves  of  the  services  of  the  men  of  unusual  skill  and  reputa- 
tion on  the  hospital  staff.  The  occupants  of  such  rooms  can  usually 
afford  to  travel  long  distances  in  the  hope  of  superior  study  or  treat- 
ment. Hospital  workers  with  national  or  international  reputation 
will,  therefore,  attract  the  interesting  clinical  puzzles  from  widely  dis- 
tant points  and   thus   extend  the   clinical  material   of   the   hospital. 


TENDENCIES    IN    MEDICAL    EDUCATION  263 

Among  the  well-to-do  there  are  sometimes  individuals  of  superior 
intelligence,  types  of  men  and  women  rarely  to  be  met  with  in  the  public 
wards  of  the  hospital.  The  stimulus  to  study  a  disease  in,  and  to  makt 
a  discovery  that  will  restore  the  health  and  activity  of  the  body  of,  a 
person  of  superior  intelligence  {e.  g.,  an  illustrious  artist,  a  scientific 
discoverer,  a  captain  of  industry,  a  leader  of  labor)  will  be  somewhat 
greater  than  the  stimulus  yielded  by  a  similar  malady  affecting  a  person 
with  mediocre,  or  distinctly  inferior,  brain  in  either  the  private  or  the 
charity  ward.  The  direct  benefit  to  society  means  more  in  the  one  case 
than  in  the  other.  The  anticipated  contributions  to  medical  knowl- 
edge in.  the  two  instances  might  be  of  equal  value  as  far  as  future  use 
by  the  profession  is  concerned,  but  the  finer  immediate  need  makes  a 
special  appeal.  This  may  account  for  the  number  of  important  thera- 
peutic measures  which  owe  their  invention  or  discovery  to  problem- 
solving  suggested  by  private  patients.  Further,  the  endowment  of 
medical  research  by  private  individuals  is  encouraged  by  the  acquaint- 
anceship with  medical  needs  that  the  private  wards  foster.  Finally,  the 
private  patients  treated  do  much  to  support  the  reputation  of  the  hos- 
pital and  its  staff  and  thus  affect  favorably  the  standing  of  the  medical 
school  and  its  graduates.* 

The  responsibilities  of  diagnosis  and  treatment  of  this  vast  collection 
of  clinical  material,  public  and  private,  stationary  and  ambulatory,  are 
a  grave  burden  which  the  clinical  staff  must  bear.  The  mere  technical 
procedures  of  the  thorough  examinations  made  and  of  the  therapeutic 
measures  carried  out  involve  a  large  expenditure  of  time  and  energy. 
Students,  house-officers,  and  senior  assistants  may  well  bear  the  brunt 
of  this  work,  but,  in  addition,  an  associate  professor,  or,  in  the  larger 
institutions,  preferably  a  full  professor,  may  well  devote  the  major 
part  of  his  time  and  energies  to  it,  leaving  most  of  the  teaching  and 

*  Certain  precautions  ought  always  to  be  taken  to  prevent  abuses ;  for 
instance,  the  private  wards  should  never  be  so  greatly  developed  that  the  public 
wards  and  the  out-patient  departments  become  a  mere  appanage  of  a  large  private 
sanitarium.  Especial  care  should  he  tal'en  that  the  teachers  and  investigators 
in  the  clinic  do  not  become  overburdened  tuith  private  patients.  It  may  be 
necessary  to  regulate  the  amount  and  distribution  among  members  of  the  staff, 
of  this  kind  of  work,  and  to  exercise  some  supervision  over  the  fees  charged. 
The  practise  in  such  wards  should  exemplify  the  highest  ethical  standards  of  the 
profession.  The  hospital  should  never  enter  into  unfair  competition  with  physi- 
cians and  surgeons  outside;  the  admission  of  patients  to  the  private  wards  of 
hospitals  with  payment  only  for  room  and  board,  and  without  the  payment  of 
fair  fees  for  professional  services  rendered,  is  unjust  to  the  practising  profession. 


264  MEDICAL   BESEABCE   AND   EDUCATION 

experimental  investigation  to  others.  The  philanthropic  work  of  the 
hospital,  as  well  as  the  reputation  of  the  institution  among  physicians 
and  among  the  laity,  depends  on  the  thoroughness  and  courtesy  with 
which  this  work  is  done.  Moreover,  the  teaching  and  investigative 
functions  of  the  clinic  can  be  properly  developed  by  those  who  are 
devoted  especially  to  them  only  after  this  fundamental  function  of  diag- 
nosis and  treatment  has  been  fully  provided  for.  The  mere  adminis- 
trative side  of  this  part  of  the  work  is  complex  and  time-consuming. 
The  admission  and  discharge  of  patients,  the  maintenance  of  records, 
the  arrangements  for  special  examinations  by  workers  in  neighboring 
clinics,  the  interviews  and  correspondence  with  the  patients'  friends  and 
relatives  and  with  their  physicians — all  require  time,  thought  and  a 
special  kind  of  skilled  executive  ability.  The  patients  are  very  different 
from  the  guinea-pigs  and  the  rabbits  of  the  laboratories,  and  can  not  be 
treated  or  operated  on  in  the  same  way.  Nor  can  you  dismiss  a  patient's 
relatives  with  that  lack  of  ceremony  which  is  sufficient  in  a  guinea-pig's 
case;  they  must  be  talked  to,  and  written  to,  occasionally.  Laboratory 
men  discussing  clinical  reforms  sometimes  seem  to  forget  this.  Even 
the  best  executive  officer  can  not  wholly  escape  from  the  matters  referred 
to,  though  as  the  organization  becomes  perfected,  the  chief  supervisor 
can  turn  over  much  to  junior  men. 

The  application  of  the  principles  of  "scientific  management"  to 
the  details  of  the  work  in  the  clinic  promises  improvements.  If  every 
element  in  the  work  of  the  clinic,  from  out-patient  department  to  pri- 
vate ward,  were  subjected  to  searching  inquiry,  much  waste  of  time, 
waste  of  energy  and  waste  of  material  could  be  eliminated.  At  present 
there  is  little  uniformity  in  the  technic  of  clinical  examinations  and  the 
personal  element  enters  far  too  greatly.  It  is  highly  desirable  that 
experts  shall  decide  on  the  one  best  method  to  use  in  each  instance, 
that  these  best  methods  shall  be  adopted  as  standards,  the  efficiency  of 
all  the  workers  being  gradually  brought  up  to  these  standards  by  careful 
instruction,  and  the  organization  made  such  that  the  plans  will  be  self- 
perpetuating.  This  task  is  far  easier  to  talk  about  than  to  accomplish, 
but  it  should  be  undertaken.^  Modern  commerce  is  developing  systems 
of  efficiency  beside  which  the  management  of  clinics  cuts  a  sorry  figure. 
We  need  a  "commercialization  of  medicine"  in  the  good  sense  and 

"Taylor,  F.  W.,  "Scientific  Management,"  New  York,  1911;  Gantt,  H.  L., 
System,  February,  1911;  Cooke,  M.  L.,  Bulletin  of  Carnegie  Foundation,  1910. 


TENDENCIES    IN    MEDICAL    EDUCATION  2C5 

must  see  to  it  that  the  term  "  medicalization  of  business  "  is  not  coined 
as  a  byword  of  reproach ! 

The  Teaching  of  Internal  Medicine 

In  the  performance  of  the  second  great  function  of  a  medical  clinic, 
that  of  teaching  in  the  wards,  in  the  dispensaries  and  in  the  clinical 
laboratories,  a  fairly  large  stafp,  a  well-thought-out  plan  and  the  devo- 
tion of  much  time  and  energy  are  essential.  The  amount  of  teaching 
in  a  department  of  internal  medicine  is,  and  should  he,  greater  than  in 
any  other  department  of  a  medical  school.  It  makes  up  a  large  pro- 
portion of  all  the  work  of  the  third  and  fourth  years,  and  from  now  on 
is  likely  to  include  also  a  part  of  that  of  the  second  year  of  the  under- 
graduate course. 

Since  the  graded  medical  course  was  inaugurated  by  Northwestern 
University  many  years  ago,  American  clinicians  have  gradually  ar- 
ranged a  sequence  of  studies  in  the  medical  clinic  which  permits  of  a 
methodical  advance  in  the  instruction.  The  student  from  the  begin- 
ning of  his  clinical  studies  is  made  regularly  and  purposefully  to  climb 
a  ladder  which  connects  the  fundamental  training  of  the  non-clinical 
departments  with  the  professional  occupation  which  he  is  to  take  up 
after  graduation.  Instead  of  the  didactic  and  merely  demonstrative 
teaching  which  formerly  prevailed,  a  thorough  practical  training  in 
clinical  work  is  now  required.  After  a  general  introduction  to  clinical 
methods  and  aims  at  the  end  of  his  second  year,  the  student  is,  in  his 
third  year,  instructed  in  the  principles  and  art  of  physical  diagnosis 
(inspection,  palpation,  percussion  and  auscultation),  and  he  is  taught, 
in  the  systematic  practical  course  given  in  the  clinical  laboratory,  how 
to  make  examinations  of  the  sputum,  urine,  stomach  contents,  feces, 
blood  and  the  various  body  fluids.  In  the  third  year,  too,  he  learns 
the  method  of  taking  clinical  histories  and  of  keeping  protocols,  hears 
a  certain  number  of  general  didactic  lectures,  attends  amphitheater 
clinics  which  stimulate  his  interest,  studies  a  good  text-book,  and  is 
tested  as  to  his  progress  by  carefully  conducted  recitations.  In  the 
latter  part  of  the  third  year  he  may  profitably  engage  in  the  actual 
history  taking,  physical  examination  and  therapy  of  ambulatory  patients 
in  the  policlinic. 

Important  as  this  propedeutic  work  is,  it  is  overshadowed  in  bene- 
fits conferred  by  the  medical  work  of  the  fourth  year,  when  the  under- 


266  MEDICAL   BE  SEARCH   AND   EDUCATION 

graduate  student  is  required  actually  to  do  an  important  part  of  the 
work  in  the  stationary  clinic.  Here,  as  a  clinical  clerk,  he  has  a  certain 
number  of  beds  assigned  to  him  and  is  permitted  to  regard  the  patients 
occupying  them  as  his  patients,  for  whose  study  and  care  he  is  person- 
ally, in  large  degree,  responsible.  These  clinical  clerkships,  the  glory 
of  the  teaching  of  medicine  in  Edinburgh  and  London,  introduced  into 
this  country  by  Osier,  and  now  meeting  with  general  adoption,  offer  the 
best  opportunity  conceivable  for  students  to  acquaint  themselves  with 
the  technic  of  the  art  of  internal  medicine.  The  task  of  giving  much 
responsibility  to  students  while  keeping  strict  control  and  exercising 
the  sharpest  and  most  thorough  supervision  over  them,  is  not  an  easy 
one,  but  it  is  being  satisfactorily  worked  out  in  our  better  clinics. 
Nothing  could  be  more  disastrous  to  patients  or  students  than  to  give 
responsibility  without  control  and  supervision;  granted  these,  patients, 
students  and  hospital  staff  alike  profit.  Since  on  entering  the  sta- 
tionary clinic  the  students  are  prepared  to  make  more  or  less  accurate 
laboratory  and  physical  examinations,  a  higher  order  of  routine  can  be 
maintained  in  the  medical  wards  with  their  help  than  would  be  possible 
with  the  staff  alone.  An  auxiliary  body  of  workers,  to  which  the 
simpler  tasks  can  be  deputed,  leaves  the  staff  at  greater  liberty  to 
devote  itself  to  the  more  difficult  technical  procedures  and  to  advanced 
studies  which  otherwise  could  have  only  a  limited  application  or  would 
have  to  be  entirely  dispensed  with. 

Students  and  staff  thus  work  together  in  the  medical  clinic  as  a 
harmonious  group.  The  cases  under  examination  are  compared  with 
similar  cases  in  the  literature.  The  spirit  of  thorough  investigation  is 
cultivated ;  each  worker  is  encouraged  to  ask  himself  how  the  particular 
cases  immediately  in  his  care  can  be  more  completely  analyzed  and 
what  problems  they  present  suggestive  of  experimental  or  statistical 
inquiry.  The  treatment  instituted  can  be  carefully  observed,  for  the 
work  is  concentrated,  the  students  practically  living  in  the  medical 
wards  for  several  months  at  a  time;  any  results  attributable  to  therapy 
can  be  observed  and  recorded.  If  a  patient  gets  well  the  students  are 
urged  to  follow  up  his  subsequent  history;  if  he  dies  they  attend  the 
autopsy  in  the  pathologic  laboratory  and  compare  the  anatomic  findings 
with  the  clinical  inferences  which  have  been  drawn  during  life. 

In  all  this  medical  work,  in  both  the  third  and  fourth  years,  it  is 
essential  that  the  students  be  divided  into  small  groups  and  that  each 


TENDENCIES    IN    MEDICAL    EDUCATION  267 

group  be  directly  supervised  by  some  member  of  the  clinical  staff.  The 
immediate  hourly  supervision  will,  of  necessity,  devolve  on  the  younger 
men  on  the  staff,  but  a  heavy  burden  also  falls  on  the  senior  members  of 
the  department  who  must,  themselves,  keep  in  intimate  touch  with  the  • 
students  and  junior  staff — controlling,  criticizing,  reviewing,  suggest- 
ing, encouraging.  At  least  one  full  professor  and  two  associate  pro- 
fessors, whose  function  shall  be  predominantly  teaching,  are  needed  to 
plan  and  to  conduct  this  work;  in  larger  clinics  it  would  be  of  advan- 
tage to  have  two  full  professors  assigned  to  this  function.  In  some  of 
the  schools,  the  teaching  professors  will  also  be  the  authors  and  revisers 
of  text-books  of  medical  practise. 

One  rewarding  part  of  the  work  of  a  teaching  professor  in  such  a 
department  is  the  instruction  given  to  the  junior  men  on  the  staff — 
the  assistants,  instructors  and  associates;  not  only  can  a  professor 
through  them  extend  his  influence  over  the  students,  but  he  will  be  able 
to  discover  in  his  staff  those  whose  native  ability  and  inclinations  give 
promise  of  teaching  power,  and  by  developing  them  provide  a  stock, 
whence  the  successors  to  those  now  teaching  may  later  be  drawn. 

The  clinic  should  also  receive,  as  far  as  its  facilities  will  permit, 
physicians  who  desire  to  take  postgraduate  courses  in  internal  medicine. 
These  physicians  fall,  roughly,  into  two  groups;  first,  graduates  of 
several  years'  standing  (or  recent  graduates  of  inferior  colleges),  who, 
like  undergraduate  students,  need  a  thorough  training  in  the  funda- 
mental methods  and  principles  of  the  clinic,  and,  second,  advanced  men, 
who,  well-trained  in  the  fundamentals,  are  ready  to  take  up  higher 
work  in  internal  medicine  and  to  specialize  in  it,  some  of  them  along 
the  lines  of  practise,  others  along  the  lines  of  teaching,  and  still  others 
along  the  lines  of  original  inquiry.  In  a  good  organization,  these 
advanced  men  would,  according  to  their  special  needs,  be  distributed 
among  the  workers  in  the  department,  some  being  sent  to  the  men 
chiefly  engaged  in  the  care  of  the  patients,  others  to  the  men  especially 
occupied  in  teaching,  and  a  select  few  to  the  men  wholly  absorbed  in 
experimental  research. 

Discovery  in  Internal  Medicine 
The  third  great  function  of  the  clinic  of  internal  medicine  is  that 
of  original  investigation.    It  is  a  fortunate  feature  of  clinical  work,  one 
doubtless  that  has  had  much  to  do  with  that  steady  progress  in  knowl- 
edge which  throughout  time  the  clinics  have  made,  that  even  the  routine 


268  MEDICAL   BESEABCE   AND   EDUCATION 

work  in  a  clinic  is  largely  work  of  research.  Each  new  patient  is  a 
problem  for  investigation;  the  clinician  applies  the  methods  he  has 
learned  and  tries  to  solve  it.  The  essentially  inquisitive  nature  of  the 
every-day  work  of  the  clinician  has  to  be  personally  known  to  be  fully 
appreciated.  In  addition  to  the  ordinary  routine  of  clinical  work, 
physicians  are  constantly  trying  out  new  methods  of  examination  and 
treatment  that  have  been  devised  and  recommended;  this  work,  care- 
fully done,  the  observations  being  accurately  recorded  and  analyzed, 
affords  material  for  statistical  inquiry,  the  results  of  which  are  often 
of  high  importance  to  the  profession.  When  a  new  method  of  deter- 
mining clinically  the  size  of  the  heart  has  been  proposed,  or  an  early 
diagnostic  test  for  typhoid  fever  or  for  syphilis  or  for  carcinoma  of  the 
stomach  suggested,  long  experiential  proving  in  the  clinics  must  decide 
as  to  its  value  before  it  is  accepted  for  general  routine.  A  great  clinic, 
scientifically  controlled,  can  thus  continually  advance  knowledge  and 
help  on  the  practical  work  of  the  profession. 

It  is,  naturally,  not  the  function  of  the  clinic  to  do  work  in  abstract 
anatomy,  physiology  or  pathology.  The  aim  and  purpose  of  the  clinic 
is,  on  the  contrary,  to  continue  the  applications  already  made,  and  to 
make  new  applications,  of  the  facts  of  anatamy,  physiology,  pathology, 
chemistry,  etc.,  to  the  solution  of  problems  in  diagnosis  and  therapy 
suggested  by  patients  who  come  to  the  clinic  for  help.  Unless  clinical 
men  fully  realize  this  point,  unless  they  have  a  full  consciousness  of 
precisely  what  the  clinic  is  for,  they  may  be  led  astray  by  those  who  feel 
that  "applied  science''  is  very  different  from  "science."^  Clinicians 
are  sure,  now  and  again,  to  make  certain  contributions  to  pure  physiol- 
ogy or  pathology  when  trying  to  solve  their  own  problems  in  diagnosis 
and  therapy.  They  will  be  glad  when  their  work  so  contributes,  but  this 
should  not  be  the  main  aim  and  purpose  of  that  work ;  as  soon  as  a  man 
in  the  clinic  finds  it  to  be  so,  it  is  time  that  he  left  the  clinic  and  trans- 
planted himself  to  a  laboratory  of  physiology  or  pathology.     Clinicians 

'  A  mathematician  sometimes  feels  that  his  work  is  more  scientific  than  the 
work  of  the  chemist  or  physicist;  the  latter,  in  turn,  is  too  prone  to  regard  the 
biologist  or  physiologist  as  an  unfortunate  worker  in  applied  science,  and  to 
speak  with  some  contempt  of  the  efforts  with  complex  and  mixed  substances 
made  by  the  biologic  chemist,  or  the  immunologist;  the  physiologist  and  the 
pathologist  again  only  too  often  fail  to  attribute  scientific  value  to  the  efforts  at 
application  of  the  facts  of  their  subjects  made  by  clinicians.  There  will  always 
be,  I  fear,  this  misunderstanding  of  the  applied  sciences  by  the  sciences  basal 
to  them. 


TENDENCIES   IN    MEDICAL    EDUCATION  269 

must  jealously  guard  opinion  in  this  matter;  otherwise  their  sciences 
can  not  satisfactorily  progress. 

In  the  United  States,  there  has  of  recent  years  developed  much 
sympathy  with  the  German  ideal,  which  requires  not  only  that  every 
university  professor  shall  know  the  results  of  the  most  recent  researches 
in  his  subject,  but  that  he  himself  shall  also  be  an  investigator  and  for- 
warder of  knowledge  in  the  branch  of  science  which  he  teaches.  A 
modern  department  of  internal  medicine,  according  to  this  ideal,  will 
be  not  only  a  place  for  transmitting  what  is  known  to  medical  students, 
but  also  a  place  in  which  the  unknown  is  actively  explored,  teachers 
and  pupils,  though  engaged  in  the  routine  work  of  the  clinic,  living  also 
in  an  atmosphere  of  original  research.  Students  profit  when  they  ob- 
serve knowledge  in  its  growth ;  to  some  extent  at  least  they  should  con- 
trol the  facts  which  they  learn  from  books  and  from  teachers  by  first- 
hand examination;  they  should  be  encouraged  to  apply  the  methods  of 
modern  scientific  investigation  to  the  objects  which  they,  themselves, 
observe.  Thus  introduced  to  the  spirit  and  method  of  scientific  inquiry, 
the  students  are  protected  from  the  dogmatism  which  so  often  accom- 
panies mere  traditional  teaching.  They  see  for  themselves  the  weak 
spots  in  internal  medicine  and  begin  to  think  of  methods  of  attacking 
them. 

In  Germany,  the  ideal  of  research  has  been  so  glorified  that  some  of 
the  professors,  even  in  the  clinical  branches,  have  devoted  themselves 
largely  to  it  with  gratifying  results  in  contributions  to  knowledge.  In 
internal  medicine,  however,  in  Germany,  the  undergraduate  teaching 
has  been  to  a  certain  extent  sacrificed  for  the  sake  of  research,  the 
system  of  clinical  clerkships  not  yet  having  been  instituted. 

In  the  United  States,  the  emphasis  has  been  laid  rather  on  the 
teaching  of  students;  clinical  research  has  been,  until  recently,  less 
cultivated.  This  may  explain  the  higher  state  of  clinical  science  in 
Germany,  on  the  one  hand,  and  the  better  physicians  trained  by  the 
good  schools  in  the  United  States  on  the  other.  Germany  ought  to  re- 
organize its  clinical  teaching  so  as  to  make  better  doctors;^  in  the 
United  States  we  should  set  about  increasing  the  scientific  productivity 
of  the  clinics.  In  both  countries  the  defects  are  becoming  clearer  in  the 
academic  consciousness;  the  evils  persist  less  from  lack  of  recognition 

^An  effort  in  this  direction,  recently  made  in  Germany,  may  be  seen  in  the 
"hospital  year"  now  required  at  the  end  of  the  medical  course  there.  It  appears 
to  correspond  to  our  hospital  internship,  made  compulsory. 


270  MEDICAL   BESEABCH   AND    EDUCATION 

of  their  existence  than  because  money  and  men  for  the  realization  of 
ideals  are  not  yet  available. 

In  order  that  clinical  research  may  make  more  rapid  advance,  and 
the  sciences  of  diagnosis  and  therapy  be  furthered,  the  experimental 
method  should  he  more  extensively  employed.  Owing  to  the  peculiar 
conditions  which  have  prevailed  in  the  clinics  up  to  now,  only  a  few 
men,  either  in  Germany  or  in  the  United  States,  have  had  the  time, 
interest,  training  and  independent  income  which  have  permitted  them  to 
do  extensive  original  work  by  experimental  methods  in  laboratories 
directly  attached  to  the  clinics.  Recently,  however,  more  of  this  work 
has  been  done.  It  has  been  very  welcome,  and  the  time  has  come  when 
it  would  seem  desirable  to  make  this  kind  of  research  more  systematic 
and  purposeful,  less  casual  and  accidental.  Each  medical  clinic,  in 
addition  to  its  laboratory  in  which  undergraduate  students  are  taught, 
and  in  addition  to  the  small  laboratories  connected  with  the  wards,  in 
which  routine  microscopic,  bacteriologic,  chemical,  radiographic  and 
electric  examinations  are  made  on  patients  or  on  materials  derived  from 
the  wards,  should  have  three  or  four  special  clinical  laboratories,  ex- 
pressly designed  for  scientific  investigative  work,  for  solving  problems 
in  diagnosis  and  therapy  which  contact  with  the  patients  in  the  clinic 
suggests.®  In  the  biochemical  laboratory  of  the  medical  clinic  the 
methods  of  modern  chemistry  may  be  applied  to  the  solution  of  clinical 
problems,  especially  those  of  metabolism.  In  the  biologic  (serologic) 
laboratory  the  problems  of  infection,  immunity,  and  experimental 
therapy  may  be  approached.  The  physiologic  division  of  the  laboratory 
may  carry  on  experiments  bearing  on  cardiovascular,  renal  and  other 
diseases.  If  a  fourth,  psychopathologic,  laboratory  be  available,  all  the 
better.  In  these  laboratories  for  medical  research  there  should  be 
medical  investigators,  especially  trained  in  the  so-called  pure  sciences  of 
physics,  chemistry  and  biology,  who  will  devote  themselves  to  the 
application  of  the  methods  and  principles  of  these  sciences  to  the  solu- 
tion of  the  special  problems  by  which  workers  in  the  clinic  are  con- 
fronted. These  men  should  he  paid  liberally  enough  to  permit  them  ta 
devote  their  whole  time  and  energies  to  research,  the  rewards  of  their 
positions  being  regularly  enhanced  during  their  productive  years. 

It  would  be  short-sighted  of  internal  medicine  to  neglect  these 
powerful  engines  of  exploration  and  enrichment.     The  other  depart- 

*"The  Organization  of  the  Laboratories  in  the  Medical  Clinic  of  the  Johns 
Hopkins  Hospital,"  Johns  Hopkins  Hospital  Bulletin,  1907,  XVIIL,   193-198. 


TENDENCIES    IN    MEDICAL    EDUCATION  271 

ments  of  applied  science  have  set  us  the  example.  Technology  has 
demonstrated  the  efficacy  of  paid  research  work  for  the  promotion  of  the 
industrial  arts  (metallurgy,  brewing,  electrical  engineering,  sugar 
refining,  food  preservation,  the  manufacture  of  arms  and  ammunition, 
etc.).  It  would  he  a  distinct  advantage  if  at  least  one  liberally  endowed 
full  professorship  were  provided  in  the  clinic  of  internal  medicine,  in 
which  a  man  of  original  ideas,  thoroughly  trained  in  methods  of  re- 
search, could,  undistracted  by  administrative  work,  by  private  or  hos- 
pital practise,  or  by  undergraduate  teaching,  devote  his  whole  time  and 
energies  to  it.  A  mind  full  of  heuristic  hypotheses,  a  curiosity  which 
compels  the  accurate  testing  of  them,  a  body  inured  to  intense  and 
confining  work,  the  privilege  of  continuous,  uninterrupted  application 
to  laboratory  studies,  a  guarantee  of  financial  independence,  liberal  sup- 
port in  the  form  of  equipment,  facilities  for  experimentation,  assistants 
and  mechanical  aids,  and  the  entire  sympathy  and  cooperation  of  those 
who  attend  to  the  major  part  of  the  practise  and  the  teaching  of  under- 
graduates in  the  clinic  would  be  necessary  to  make  the  venture  fruitful. 
Assume  the  existence  of  such  conditions  in  our  departments  of  internal 
medicine,  and  find  for  the  research  professorships  men  of  the  type  of 
Louis  Pasteur,  Eobert  Koch,  Paul  Ehrlich  or  Simon  Flexner — what 
dare  we  not  expect  in  the  way  of  extension  of  diagnostic  recognitions 
and  of  means  of  cure  ? 

And  what  an  opportunity  such  an  arrangement  would  offer  for  post- 
graduate study !  A  few  advanced  scholars,  desiring  to  widen  the  science 
of  internal  medicine,  could  cooperate  with  such  a  research-professor  in 
the  "master  work-shop,"  and,  according  to  their  ability,  experience  the 
wonderful  Joy  of  creative  work.  One  who  has  once  been  permitted  so  to 
participate  will  never  forget  it.  Many  regard  this  last  and  highest 
phase  of  personal  education  as  the  acme  of  their  inner  experience.® 

Despite  the  unfavorable  conditions  now  existing  in  the  clinical  de- 
partments, strong  men  have  been  attracted  to  them.  All  things  con- 
sidered, patients  are  being  very  well  cared  for,  good  physicians  are  being 
trained,  a  very  fair  amount  of  original  work  has  been  produced.  The 
bibliographic  output,  including  text-books,  handbooks  and  publications 
of  original  research,  compares  favorably  with  that  of  any  one  of  the 
laboratory  subjects.  As  to  foreign  recognition,  it  has  been  fully  as  great 
for  the  clinical  chairs,  if  not  greater,  than  for  the  non-clinical  depart- 

•  Cf .  Ostwald,  W.,  Die  Umschau,  January,  1911. 


272  MEDICAL   BESEABCH   AND   EDUCATION 

ments.  Many  foreign  clinicians  have  visited  American  clinics  and  most 
of  the  foreign  students  who  have  come  to  this  country  to  work  have 
entered  clinical  rather  than  non-clinical  departments.  Several  clinical 
text-books  have  been  and  are  being  translated  into  other  languages. 

The  Movements  Toward  Reform 

The  tedium  of  this  long  description  of  the  functions  of  a  medical 
clinic  would  scarcely  be  justifiable  were  it  not  for  my  desire  clearly  to 
establish  a  fact  of  importance,  namely,  the  growth  of  the  functions  of 
the  clinic  to  a  size  and  complexity  no  longer  compatible  with  the  form 
of  its  present  organization. 

Hitherto  there  has  been  only  one  professor  at  the  head  of  a  clinical 
branch,  and  he  has  been  supposed  to  engage  in,  care  for  and  control  all 
these  varying  activities  and,  in  addition,  to  make  the  major  part  of 
his  income  in  practise  outside  the  hospital,  only  a  few  institutions,  thus 
far,  having  been  able  to  pay  salaries  which  would  defray  even  a  portion 
of  the  cost  of  the  clinician's  living.  Surely  the  superhuman  has  been 
expected ! 

We  have  now  briefly  to  consider  how  the  clinics  can  best  be  organized 
to  meet  modern  requirements,  and  I  shall  again  refer  chiefly  to  the 
medical  clinic,  assuming  that  a  plan  which  will-  suit  its  exigencies  may, 
with  certain  modifications,  be  applicable  to  the  other  clinics. 

The  first  step  toward  improvement  will  consist  in  the  spread  of  the 
conception  of  the  clinic  as  elaborated  above,  in  the  recognition  of  the 
need  of  a  functional  division  of  labor  in  the  clinic  corresponding  to  the 
growth  and  enrichment  of  its  varied  activities  and  to  the  different  types 
and  qualities  of  men  attracted  to  the  tasks  and  problems  of  clinical 
fields.  Differentiation  is  perhaps  the  most  characteristic  feature  of 
progress  of  mind ;  once  we  have,  through  an  intellectual  process,  resolved 
the  complexity  of  the  clinic  into  its  main  divisions,  it  would  be  folly  to 
ignore  the  sense  of  achieved  distinctions,  and  real  stupidity  to  lose  what 
we  have  gained,  by  again  confusing  things  which  right  reason  has  put 
asunder.  In  manning  the  clinic  of  internal  medicine,  we  should,  there- 
fore, keep  in  mind  the  constitutent  functions,  choose  enough  men  and 
assign  them  to  duties  accordingly. 

Whether  to  make  (1)  vertical  sections  through  the  clinic  with 
especial  reference  to  the  three  great  functions  of  {a)  practise,  (&) 
teaching  and  (c)  research  throughout  the  hospital,  the  undergraduate 
medical  school  and  the  postgraduate  work,  or  (2)  transverse  sections 


TENDENCIES    IN    MEDICAL    EDUCATION  273 

at  the  levels  of  (a)  the  routine  hospital  work,  (6)  the  undergraduate 
instruction  and  (c)  the  postgraduate  instruction,  are  questions  for  the 
wise  to  decide.  Though  I  lean  to  the  latter  method,  it  is  surprising, 
on  consideration,  how  similar  the  division  of  labor  would  work  out, 
whichever  way  the  sections  were  cut.  Those  who  devote  themselves 
chiefly  to  the  care  of  patients  in  the  clinic  need  not  be  men  who  do  a 
great  deal  of  teaching  and  investigation.  Those  who  are  mainly  respon- 
sible for  the  teaching  in  the  undergraduate  school  should  not  be 
burdened  with  the  care  of  too  many  patients  and  would  of  necessity 
have  to  limit  the  time  given  to  investigation.  Those,  in  turn,  who  give 
their  time  and  energies  almost  wholly  to  research  should  be  protected, 
as  far  as  possible,  from  the  teaching  of  undergraduate  medicine  and 
from  the  cares  of  practise  and  administration. 

Here,  then,  we  have  in  mind  a  clean-cut  conception  of  an  ideal  of 
organization  toward  which  we  may  strive.  T\Tiat  is  now  a  single  pro- 
fessorship could  be  replaced  by  a  cooperative  committee  of  professors  in 
charge  of  a  large  and  differential  staff.  In  small  and  less  liberally  en- 
dowed colleges  it  may  be  necessary  to  be  content  with  one  professor  and 
a  group  of  associate  professors  or  associates.  In  the  larger  colleges  with 
greater  funds  a  group  of  full  professors  should  be  found  and  supported. 
The  so-called  "headship  of  the  department"  could  be  matter  of  elec- 
tion, or  rotation,  or  there  might  even  be  "  government  by  commission " 
within  the  department.  In  any  case  provision  should  be  made  for 
regular  conferences  in  which  the  leaders  of  the  work  should  be  inti- 
mately and  harmoniously  associated.  This  maintenance  of  the  unity  of 
the  clinic  seems  to  me  better  than  the  disintegration  toward  which  we 
are  at  present  tending  (establishment  of  separate  research  institutes; 
creation  of  chairs  of  experimental  medicine,  experimental  pathology  and 
experimental  therapy),  though  the  creation  of  several  separate  depart- 
ments would  be  better  than  a  continuance  of  the  single  department  in 
its  present  overworked  and  undermanned  state. 

In  an  address  delivered  some  years  ago,  entitled  "Medicine  and 
the  Universities,''^"  I  made  some  suggestions  regarding  the  clinical 
branches ;  even  then,  though  I  was  engaged  entirely  in  laboratory  work, 
it  seemed  to  me  that  the  clinics  were  undermanned  and  that  the  work 
in  them  was  insufficiently  differentiated.  In  that  address  it  was  inti- 
mated that  the  time  might  come  when,  in  the  clinical  branches,  we 

^'^  American  Medicine,  Philadelphia,  1904.     [Eeprinted  in  this  volume,  q.  v.] 
19 


274  MEDICAL   BE  SEARCH   AND   EDUCATION 

should  have  at  least  two  kinds  of  professors:  (1)  Professors  on  a  so- 
called  "university  basis,"  paid  salaries  large  enough  to  enable  them  to 
devote  their  whole  time  and  energy  to  teaching  and  investigation,  with- 
out engaging  in  private  practise;  and  (2)  professors  who  give  a  part  of 
their  time  to  the  care  of  patients  in  the  hospital,  to  teaching,  and  to  in- 
vestigation, and  who,  though  paid  smaller  salaries,  obtain  their  income 
chiefly  from  the  fees  of  private  patients,  preferably  from  consultative  or 
operative  work.  The  ideas  there  set  forth,  in  the  main,  still  hold  good, 
though  it  is  doubtful  if  they  can  be  applied  in  precisely  the  manner  I 
then  suggested.  Though  the  clinic  then  seemed  complex,  I  know, 
to-day,  even  more  of  its  intricacies  and  difficulties,  and  the  problem 
looks  less  simple  in  solution  at  close  range  than  it  did  at  a  distance. 

"Were  a  new  medical  school  to  be  started,  with  liberal  endowment,  it 
would  be  an  interesting  experiment  to  try  an  organization  in  which  a 
functional  division  of  labor,  such  as  I  have  outlined,  is  provided  for  and 
in  which  some  of  the  professors,  especially  those  devoting  themselves 
almost  entirely  to  research,  will  be  paid  sufficient  salaries  to  permit 
them  to  escape  from  practise. 

It  has  hitherto  been  taken  for  granted  that  the  professor  of  medicine 
in  the  medical  school  would  engage  in  medical  practise  and  that  the 
professor  of  surgery  would  have  his  private  patients,  each  reaping  the 
financial  rewards  attending  on  such  work.  The  prominence  of  such 
men  and  their  unusual  training  and  opportunities  have  made  them,  as 
a  rule,  much-sought  consultants  rather  than  general  practitioners, 
though  many  of  them  naturally  began  with  general  private  practise  in 
their  respective  branches,  and,  as  their  work  grew,  limited  it,  later,  to 
consultative  or  operative  practise.  Only  rarely  have  the  occupants  of 
clinical  chairs  been  paid  living  salaries.  As  a  rule  the  clinical  teachers 
have  had  to  depend  for  their  living  on  the  fees  of  private  patients.  As 
a  man's  reputation  grows  with  the  public,  the  demand  on  him  from  out- 
side becomes  more  and  more  pressing  and  difficult  to  withstand  and  is 
likely  to  encroach  ever  more  on  the  time  which  the  clinic  itself  requires. 
Though  some  men  of  strong  character  and  unusual  sense  of  order  may 
systematically  apportion  their  time  so  as  to  protect  themselves  and  the 
clinic  from  a  clamoring  public,  not  all  men  are  able  to  do  so,  and  our 
great  medical  schools  show  more  than  one  example  of  professors  who, 
in  the  earlier  part  of  their  incumbency,  have  devoted  a  large  part 
of  their  time  and  energy  to  the  hospital  and  medical  school  and, 
later  on,  have  become  so  involved  in  practise  as  to  make  them  less 


TENDENCIES    IN    MEDICAL    EDUCATION  275 

valuable  for  teaching  and  investigation.  Even  when  men  are  strong 
enough  and  systematic  enough  to  maintain  a  fixed  relationship 
among  their  several  activities,  hospital  work,  teaching,  research  and 
consultative  practise,  the  question  has  been  raised  whether  the  increased 
material  rewards  enjoyed  by  such  men  may  not  be  harmful  to  the  men 
themselves  and  to  the  clinics  in  which  they  work.  This  objection,  urged 
especially  by  those  who  favor  a  general  movement  toward  socialism,  the 
substitution  of  salaried  public  service  for  private  enterprise,  is  one  which 
should  be  carefully  considered  by  medical  educators.  The  whole  sub- 
ject is  now  being  much  discussed  and  the  fact  that,  thus  far,  no  una- 
nimity of  opinion  has  been  arrived  at  makes  it  probable  that  a  good 
deal  is  to  be  said  on  both  sides. 

In  our  reorganized  medical  schools  it  does  not  seem  to  me  probable 
that  it  will  be  desirable  soon,  if  ever,  to  have  all  the  men  of  the  faculty 
composed  of  non-practitioners.  It  would  seem  distinctly  advantageous 
to  have  at  least  some  of  the  teachers  of  undergraduates  and  some  of  the 
men  who  care  for  the  patients  in  the  hospital  also  engaged  in  private 
practise,  at  least  in  consultative  or  in  operative  work. 

In  all  attempts  at  reconstruction  our  efforts  should,  at  first,  be  ten- 
tative. It  would  be  a  mistake  to  start  with  any  cut  and  finished  gar- 
ment that  we  should  ask  the  medical  schools  immediately  to  don. 
Though  having  the  essentials  of  our  ideals  in  mind,  the  proper  method 
of  attaining  to  them  and  the  proper  expedients  would  have  to  be  slowly 
established.  At  an  early  stage  of  reform,  anything  like  extreme  meas- 
ures should  be  sedulously  avoided.  In  making  profound  changes  the 
process  of  transition  must  not  be  flatly  ignored.  The  ideal  clinic  can 
scarcely  be  attained  by  proclamation.  The  obstacles  in  the  way  of 
progress  must  be  carefully  measured  and  we  must  keep  in  mind  the 
cardinal  fact  that  "all  true  development  and  progress  are  out  of  and 
because  of  what  has  gone  before." 

It  is  among  the  inconveniences  attending  all  important  reforms  that 
the  disciple  overstates  the  teacher,  exaggerates  some  features  of  his 
doctrine  and  is  oblivious  to,  or  insufficiently  appreciative  of,  others. 
There  is  always  danger  of  confusing  novelty  with  originality  and  altera- 
tion with  progress.  Because  we  desire  research  is  no  reason  for  doing 
away  with  teaching  and  practise  in  the  clinic.  N'or  would,  in  my 
opinion,  the  limitation  of  every  professor  in  a  university  to  the  material 
rewards  of  an  insufficiently  salaried  position  prove  a  panacea  or  a  magic 
"open  sesame"  to  the  medical  millennium. 


276  MEDICAL   BESEABCR   AND   EDUCATION 

Some  enthusiasts  urge  the  summary  dismissal  of  the  clinical  pro- 
fessors now  active  and  the  substitution  of  non-practising  men.  Even  if 
this  were  advantageous  for  all  the  chairs,  as  some  erroneously  think,  it 
would  be  difficult  to  apply  such  an  organization  abruptly  in  the  schools 
already  established.  Men  who  now  occupy  the  clinical  chairs  and  who 
have  of  necessity  ordered  their  lives  for  the  double  function  of  pro- 
fessorship, on  the  one  hand,  and  of  consultative  or  operative  work  on  the 
other,  have  become  so  involved  in  obligations  that  they  could  not  sud- 
denly change  to  a  salaried  basis  without  great  hardship  to  themselves 
and  their  families,  and  loud  complaints  from  the  public.  The  cost  of 
living  of  one  who  has  to  make  the  larger  part  of  his  income  by  consul- 
tative work  in  internal  medicine,  or  operative  work  in  surgery,  is  of 
necessity  wholly  other  than  that  of  a  professor  who  limits  his  work 
entirely  to  the  university  and  lives  on  a  salary.  The  former  has  to  have 
a  different  kind  of  house,  in  a  different  part  of  the  city;  rapid  and 
easy  transit  is  necessary  for  him  if  he  is  to  husband  his  time  and  his 
energy,  and,  in  general,  he  is  involved  in  a  scale  of  expenditure  corre- 
spondent to  the  life  he  leads.  If  it  were  demanded  that  these  men 
should  abruptly  become  whole-time  professors,  and  give  up  the  remu- 
neration they  now  receive  from  private  patients,  it  would  mean  the 
elimination  of  the  majority  of  them  from  the  medical  faculties  and  their 
replacement  by  younger  and  less  experienced  clinicians.  Now,  the 
majority  of  our  leading  clinical  men  to-day  would,  I  believe,  of  their 
own  free  will  give  up  their  chairs  to  so-called  "whole-time"  men  and 
be  content  to  withdraw  or  to  be  part-time  professors  if  large  endow- 
ments for  the  purpose  were  at  hand,  if  a  great  reform  in  the  clinical 
subjects  could  thus  be  made  and  a  sufficient  number  of  adequately 
trained  and  intellectually  able  men  could  be  secured  to  take  their  places. 
But  it  may  well  be  doubted  whether  a  sufficient  number  of  entirely 
suitable  men  are  now  available  for  the  purpose.  Hitherto  there  have 
been  no  endowed  clinical  professorships,  and  should  they  be  established, 
men  would  have  to  be  trained  especially  for  them.  For  this  reason 
alone,  the  change  could  not  be  promptly  brought  about ;  and  besides,  any 
extreme  and  harsh  measure  like  compulsory  expropriation  of  the  chairs 
might  do  damage,  inasmuch  as  anything  that  makes  the  tenure  of  uni- 
versity professorships  insecure  injures  the  universities. 

It  must  be  kept  definitely  in  mind  that  the  majority  of  the  present 
incumbents  of  clinical  chairs  hold  them  in  good  faith;  that  they  do 
their  best  in  the  conditions  that  now  exist;  that  they,  as  much  as  any 


TENDENCIES    IN    MEDICAL    EDUCATION  277 

group,  desire  to  see  the  clinical  subjects  advanced,  to  have  the  patients 
better  cared  for,  to  improve  the  teaching,  and  to  augment  the  scientific 
output.  The  rightfulness  of  the  kind  of  work  the  clinical  men  are 
doing  has  always  been  taken  for  granted.  It  may  be  a  mistake  for  our 
medical  schools  to  continue  to  have  all  clinical  professorships  as  they 
have  been ;  it  may  become  educationally  advantageous  radically  to  alter 
the  vast  tradition  of  relationships  in  which  clinical  teachers  now  live. 
If  so,  the  change  can  doubtless  be  brought  about  in  an  orderly  and 
reasonable  manner,  and  no  ingratitude  should  be  shown  to  those  who 
up  to  now  have  tried  to  hold  the  torch  aloft  under  unfavorable  condi- 
tions. Above  all,  all  honest,  earnest,  hard-working  men  should  be 
protected  from  the  zeal  and  over-statements  of  headlong  advocates  who 
insinuate  the  "  absence  of  ideals "  among  clinical  men,  or  talk  of 
"  graft,"  "  rascality,"  "  commercialism  "  and  the  "  exploitation  of  the 
clinical  chairs  for  private  profit." 

The  reconstruction  in  the  clinical  departments,  when  it  is  under- 
taken, ought,  therefore,  to  be  a  sane  and  gradual  process,  a  process  of 
careful  readjustment  to  changing  conditions,  going  only  as  fast  as  men 
can  be  suitably  trained  and  academic  opinion  correspondingly  educated. 
Carried  on  in  such  a  way,  the  reforms  will  be  welcomed  and  hastened 
by  every  progressive,  right-thinking  clinician.  Our  better  physicians 
and  surgeons  are  broad-minded  men;  they  are  by  no  means  devoid  of 
the  quality  of  self-abnegation  nor  of  the  spirit  of  public  service ;  on  the 
contrary,  they  are  entirely  capable  of  assuming  their  fair  share  of 
renunciations  when  conditions  demand  them,  and  of  making  personal 
sacrifices  for  the  general  good.  Convince  such  men  of  the  evil  which 
exists  and  they  will  be  no  antagonists  to  the  forces  of  reform,  but,  on 
the  contrary,  willing  leaders  of  those  who  try  to  root  the  evil  out. 

After  provision  has  been  made  for  school-controlled  hospitals,  in 
which  students  may  live  and  work,  we  must  find  places  for  the  different 
kinds  of  clinical  men — practitioners,  teachers,  investigators.  There  is 
room  for  all  three  types,  and  all  three  Tcinds  of  work  are  desirable  and 
honorable.  We  have  a  homely  saw  to  the  effect  that  square  pegs  should 
not  be  put  into  round  holes,  an  adage  which  finds  its  more  polished 
equivalent  in  the  Greek  "  Character  is  Fate."  In  every  branch  in  a 
medical  school  students  should  come  into  contact  with  the  stimulating 
investigator  who  is  ever  pushing  forward  the  boundaries  of  knowledge ; 
he  should  learn  the  main  facts  that  have  already  been  discovered  from 
a  teacher  who  knows  how  to  collect  them  and  to  transmit  them  to  others, 


278  MEDICAL   BESEAECH   AND   EDUCATION 

and  he  should  have  the  opportunity  of  watching  the  example  of  prac- 
titioners who  come  into  contact  with  all  sorts  of  patients  and  all  sorts 
of  doctors,  who  are  acquainted  with  the  great  variety  of  clinical  puzzles 
which  are  presented  to  the  consultant  for  solution  and  who  learn  the 
virtues  and  defects  of  the  men  now  engaged  in  medical  practise  in 
different  parts  of  the  country. 

After  giving  these  matters  much  consideration,  there  is  one  sugges- 
tion that  I  should  like  to  offer  as  an  immediate  means  of  magnifying 
the  scientific  productivity  of  our  clinics  and  of  training  men  for  leader- 
ship in  them.  Provide  endowment  for  the  maintenance,  in  each  clinic, 
of  a  group  of  young  scientists  of  proved  ability  and  capacity  for  develop- 
ment, and  relieve  these  men  of  most  of  the  routine  worlc  of  teaching 
and  the  care  of  patients,  that  they  may  have  leisure  for  investigative 
work  in  the  wards  and  clinical  laboratories.  A  suggested  scale  of 
remuneration  for  such  men  might  be  an  initial  salary  of  $800  or  $1,000 
per  year  and  living  in  the  hospital,  with  a  yearly  increase  of  $200  or 
more  for  the  next  ten  years.  These  men,  so  kept  at  work  during  their 
most  productive  years — usually  between  the  ages  of  25  and  45 — 
would  rapidly  increase  the  scientific  output  of  the  clinics,  and  would 
speedily  form  a  group  of  scientific  men  in  the  clinical  branches  from 
among  whom,  later  on,  professors  in  medical  sdiools  and  investigators 
in  research  institutes  could  satisfactorily  be  chosen.  Appointed  to  pro- 
fessorships, men  so  selected  would  not  need  to  be  hedged  about  by  too 
great  restrictions ;  their  training  in  scientific  methods  and  ideals  would 
have  been  such  that  they  could  not  quickly  be  spoiled.  There  should 
then  be  no  attempt  to  interfere  with  the  full  play  of  their  individu- 
alities ;  their  positions  should  be  made  as  unhampered  as  possible ;  they 
would  of  themselves  chip  away  "the  spendthrift  liberties  that  waste 
liberty,"  and  devotedly  give  their  time  and  energies  to  the  advance- 
ment of  the  subjects  they  represented.  Their  appointments  as  pro- 
fessors might  automatically  cease  at  the  end  of  a  given  term  of  years, 
or  when  a  certain  age  limit  had  been  reached. 

This  occasion  does  not,  of  course,  permit  of  any  full  discussion  of 
the  points  I  have  raised.  Perhaps  I  have  said  enough  to  call  some  of 
the  interests  to  mind  and  to  assure  you  that  the  men  connected  with 
the  medical  schools  in  the  United  States,  like  those  in  Canada,  are 
doing  all  they  can  to  elevate  standards  and  to  improve  conditions  in 
that  noblest  of  all  professions — medicine. 


CERTAIN    IDEALS    OF   MEDICAL   EDUCATION^ 

By  Charles  S.  Minot,  D.Sc,  LL.D., 

James  Stillman  Professor  of  Comparative  Anatomy,  Harvard 

University 

It  is  the  function  of  the  teacher  to  perpetuate,  by  transmission  to 
the  oncoming  generation,  the  knowledge  and  traditions  on  which 
civilization  is  based.  We  who  have  for  our  share  of  this  indispensable 
work  the  transmission  of  medical  knowledge  and  of  medical  traditions 
find  the  difficulties  of  getting  our  freight  into  the  depots  of  youthful 
minds  always  numerous  and  often  great.  We,  therefore,  are  constantly 
busy  with  efforts  to  improve  our  transactions  by  selecting  the  most  valu- 
able knowledge  to  transfer,  by  seeking  devices  to  quicken  the  business, 
and  by  trying  to  save  the  labor-waste  of  the  students.  We  have,  besides, 
to  add  daily  to  our  stock  all  the  latest  novelties.  Despite  all  these 
pressing  demands,  we  must  keep  the  whole  army  of  data  in  perfect 
order,  under  the  command  of  general  ideas  and  of  natural  laws.  It  is 
inevitable  that  the  pressure  on  our  energies  should  absorb  most  of  their 
power  so  that  we  are  habitually  too  busy  to  pause;  and  yet  it  is,  I  am 
sure,  helpful  to  pause  occasionally  to  consider,  not  the  details,  not  the 
ways  and  means  of  our  business,  but  its  underlying  principles. 

May  I  regard  this  hour  as  such  a  pause,  which  we  dedicate  to  an 
examination  of  the  purposes  of  medical  education  and  their  best  ful- 
fillment? The  function  of  a  good  medical  school  is  to  produce  com- 
petent practitioners  of  medicine.  I  can  not  venture  to  call  this  an 
original  idea  of  my  own.  Though  it  is  a  platitude  to  which  all  assent, 
it  has  its  place  here,  in  order  to  permit  us  to  add  that  it  is  not  the  sole 
function  of  a  good  medical  school,  for  only  that  medical  school  attains 
a  high  place,  or  even  real  importance,  which  adds  on  a  large  scale  to 
medical  knowledge  and  trains  a  steady  succession  of  young  men  to 
become  medical  teachers.  Only  by  the  active  pursuit  of  these  high  aims 
can  the  influence  of  a  medical  school  inspire  sound  professional  ideals  in 

^  Commencement  Address  delivered  before  the  Medical  School  of  Washington 
University,  St.  Louis,  May  27,  1909.  Published  in  The  Journal  of  the  American 
Medical  Association,  August  14,  1909. 

279 


280  MEDICAL   BESEABCH   AND    EDUCATION 

the  minds  of  its  students,  practitioners  to  be.  It  appears,  then,  more 
accurate  to  put  our  platitude  thus:  The  chief  function  of  a  medical 
school  is  to  produce  practitioners. 

The  Essential  Qualities  op  a  Physician 

If  we  are  to  proceed  intelligently,  we  must  begin,  it  seems  to  me, 
with  an  inquiry  as  to  what  are  the  qualities  which  a  physician  should 
have,  and  the  development  or  acquisition  of  which  by  students  a  medical 
school  ought  to  render  possible. 

There  is  one  quality  the  possession  of  which  is  the  supreme  need  of 
the  physician,  without  which  he  is  as  unfit  and  useless  as  a  tone-deaf 
musician,  or  a  color-blind  painter.  It  is  a  quality  with  which  every 
normal  man  is  naturally  endowed,  just  as  every  normal  man  is  endowed 
with  hearing  and  sight.  But  just  as  it  is  true  that  not  every  man 
can  become  a  musician  or  an  artist,  so  is  it  also  true  that  for  most  men 
it  is  impossible  to  become  good  physicians,  for  the  reason  that  they  lack 
the  one  fundamental  indispensable  quality,  that  rare  gift — a  faculty  of 
exact  observation. 

Accurate  observation  is  by  far  the  most  difficult  art  which  mankind 
has  ever  essayed.  A  nation  may  count  on  furnishing  abundance  of 
military  talent — I  begin  with  the  lowest  profession — plenty  of  poli- 
ticians and  statesmen,  enough  of  competent  lawyers ;  it  may  even  hope  to 
have  gifted  artists  and  authors ;  but  it  can  scarcely  expect  to  produce  a 
single  master  of  the  art  of  observation  in  a  century.  It  is  important  to 
realize  this  fact.  Although  the  fact  itself  is  beyond  discussion,  its 
significance  is  little  heeded.  The  reasons  for  it  are  not  far  to  seek.  In 
most  occupations  a  partial  success  is  valuable ;  if  a  good  result  is  gained 
it  has  a  practical  value.  If  a  general  wins  a  campaign,  he  is  victorious ; 
yet  there  probably  was  never  a  war  which  might  not  have  been  ended 
with  less  than  the  actual  loss  to  the  victors.  A  statesman  whose  con- 
structive work  benefits  his  country  still  does  not  produce  perfect  laws. 
Bismarck  always  dreaded  the  unforeseen  consequences  of  his  statesman- 
ship. Lawyers  have  proved  themselves  useful,  though  litigation  due  to 
their  imperfect  work  is  incessant.  A  beautiful  poem  or  picture  may  be 
a  precious  joy  without  reaching  to  the  standard  of  absolute  perfection. 
Scientific  observation,  on  the  contrary,  aims  for  the  absolute,  and  so  far 
as  it  fails  to  establish  the  absolute  truth  it  must  be  renewed,  tried  again 
and  again,  until  every  blemish  is  removed  from  it.     Observation  is  ac- 


IDEALS    OF    MEDICAL    EDUCATION  281 

curate  and  good  only  when  it  attains  absolute  perfection.  Religion  sets 
before  us  an  ideal  of  absolute  moral  perfection.  All  other  ideals  of 
men  admit  of  limitations,  allow  of  boundaries,  save  in  our  waking 
dreams  and  saving  else  only  science,  which  claims  from  us  the  ideal 
of  perfect  observation,  which  alone  can  reveal  the  absolute  truth. 

In  most  professions  merit  is  measured  by  a  finite  scale,  but  the 
scientific  observer  must  strive  toward  the  Absolute,  which  to  our  human 
powers  seems  infinitely  remote.  Because  the  ideal  is  so  lofty  very 
few  come  near  it.  In  a  century  Germany  produces  one  Helmholz, 
France  one  Pasteur,  England  one  Darwin — an  American  peer  of  these 
three  is  yet  to  become  known. 

Observation  is  much  more  than  seeing,  hearing  and  feeling.  Our 
sensory  perceptions  are  but  the  beginning,  and  the  simplest  link  in  the 
chain  of  processes.  Yet  in  my  experience  no  young  man,  without  pro- 
longed and  severe  discipline,  can  be  trusted  to  forge  aright  even  this 
first  link  on  the  anvil  of  opportunity.  To  appreciate  the  real  difficulties, 
we  must  pass  behind  the  scenes  and  study  the  mental  apparatus. 

The  faults  of  the  observer  are  to  be  explained  not  so  much  by  the 
working  of  his  eye  as  by  the  failure  to  work  of  his  brain.  The  organs 
of  sense  are,  as  the  physiologists  have  taught  us,  imperfect,  severely 
limited  in  their  scope  and  ever  ready  to  furnish  us  with  defective  sensa- 
tions and  illusions,  but  they  work  with  astonishing  accuracy  as  com- 
pared with  the  mind.  In  my  long  career  as  a  teacher  of  medical  sci- 
ence, I  have  had  only  two  students  whose  eyes  were  not  equal  to  good 
microscopic  vision,  but  I  have  never  had  even  a  single  student  whose 
mind  could  perceive  the  retinal  images  obtained  from  microscopic 
preparations. 

Successful  scientific  observation  depends  on  three  psychic  factors: 
intelligence,  concentrated  attention  and  judgment.  Intelligence  is 
necessary  to  guide  the  observer,  who  must  before  he  begins  have  a  clear 
understanding  of  the  conditions  by  which  the  character  of  his  observa- 
tions is  determined  or  modified.  Above  all,  there  must  be  an  in- 
telligent appreciation  of  what  to  look  for,  and  an  intelligent  technical 
acquaintance  with  the  methods  to  be  employed.  Only  to  a  very  limited 
extent,  indeed,  can  the  direct  observation  of  natural  conditions  suffice. 
Herein,  to  my  thinking,  lies  perhaps  the  most  characteristic  distinction 
between  ordinary  and  scientific  observation:  the  latter  relies  constantly 
on  factors  artificially  introduced  to  expose  objects  too  hidden  or  to  re- 


282  MEDICAL   BESEABCH   AND   EDUCATION 

cord  phenomena  too  remote  or  swift  for  observation.  Indeed,  science  is 
based  on  the  invention  of  methods  of  research,  and  the  introduction  of 
each  new  method  is  followed  by  an  advance  of  knowledge.  In  order  to 
realize  this,  we  have  merely  to  think  what  we  owe  to  the  methods  of 
injection,  of  staining  sections  and  bacteria,  of  making  graphic  records  of 
the  pulse  and  muscular  contractions,  of  filtration  and  dialysis,  of  electric 
measurements,  and  so  on  through  a  list  of  immense  extent.  Without 
these  numerous  artificial  methods  our  sciences  would  have  remained 
rudimentary.  Intelligence  is,  therefore,  especially  necessary  to  master 
methods,  and  no  training  in  any  natural  science  is  more  than  a  farce 
which  does  not  give  the  student,  first  of  all,  a  practical  acquaintance 
with  the  methods  used  and  of  their  advantages  and  their  errors. 

Concentrated  attention  we,  of  course,  all  know  is  indispensable,  but, 
like  other  virtues,  it  is  easier  to  commend  than  to  practise.  It  is  com- 
fortable, after  receiving  a  general  impression,  to  pass  on  to  something 
different  with  a  fresh  interest ;  but  power  is  only  for  those  who  can  sus- 
tain the  closest  attention  for  a  long  time,  because  otherwise  details  are 
overlooked,  and  the  anticipated  fact  remains  unnoticed.  The  ability 
to  catch  hold  of  the  wholly  unforeseen  and  significant  phenomenon  is 
the  distinctive  gift  of  a  great  mind.  We  are  mentally  blind  to  what  we 
do  not  anticipate  or  at  least  know  as  a  possible  occurrence.  The  history 
of  science  is  rich  in  illustrations  to  the  point.  One  such  curious  illustra- 
tion I  may  mention.  For  many  years  the  red  blood  corpuscles  of  man 
and  other  mammals  have  been  described  as  like  biconcave  discs  in  shape, 
but  this  form  is  to  be  observed  really  only  as  an  artefact,  and,  as  we  now 
know,  the  corpuscles  in  life  are  cup-shaped,  being  hollow  on  one  side  and 
convex  on  the  other.  The  truth  has  been  known  to  us,  however,  only  a 
very  few  years,  because  every  one  who  examined  the  blood  had  a  precon- 
ception of  the  corpuscular  form,  and  was  mentally  blind  to  the  evidence 
as  to  the  real  shape,  of  which  any  one  can  now  easily  satisfy  himself, 
because  his  attention  will  be  rightly  directed.  Innumerable  instances 
could  be  compiled  of  scientific  discoveries  long  missed  because  of  failure 
to  attend  to  some  unexpectedly  significant  fact.  It  is  by  trained  atten- 
tion that  we  achieve  accuracy  and  thoroughness ;  hence  the  first  aim  of 
the  instruction  in  every  scientific  laboratory  should  be  to  impart  to  the 
student  a  habit  of  relentless  attention  and  a  high  standard  of  exhaustive 
precision  of  observation.  The  quantity  of  information  acquired  is  of 
minor  importance. 


IDEALS    OF    MEDICAL    EDUCATION  283 

Judgment  is  the  highest  quality.  By  attention  and  intelligence  we 
may  gather  data,  but  judgment  coins  them  into  conclusions  for  the  in- 
tellectual commerce  of  the  world.  Judgment,  as  here  conceived,  is 
much  more  than  the  judicial  faculty,  which  is  merely  skill  in  balancing 
the  pros  and  cons — a  useful  legal  faculty,  for  the  law  courts  deal  with 
evidence  mostly  from  average  persons  who  are  often  biased  by  their 
interests,  and  in  any  case  are  ordinarily  incapable  of  accurate  observa- 
tion. The  law  courts  also  follow  a  method,  that  of  having  opposing 
counsel  on  the  two  sides,  which  is  absurd  in  science,  though — ^be  it  con- 
fessed with  sadness — ^this  deplorable  method  is  often  mimicked  in  scien- 
tific debates.  The  scientific  method  is  based  on  our  belief  that  invari- 
ably the  evidence  must  be  wholly  and  exclusively  on  one  side.  If  there 
is  an  apparent  conflict,  the  duty  of  judgment  is  to  find  out,  first,  what 
part  of  the  evidence  is  erroneous;  second,  what  logical  errors  have  oc- 
curred in  the  inductions  drawn  from  the  observations.  As  to  the 
observed  data,  judgment  must  decide,  first,  whether  they  are  to  any 
extent  erroneous;  second,  to  what  extent  they  are  incomplete.  For 
such  a  decision  in  any  department  of  research  to-day  a  thorough  expert 
knowledge  of  the  special  subject  is  necessary,  which  must  include  not 
only  intimate  acquaintance  with  all  previous  work — a  requirement  too 
often  shirked — but  also  intimacy  with  all  the  possible  sources  of  error. 
Scientific  judgment  is  a  mental  faculty  which  becomes  efficient  only 
after  long  experience  and  development.  It  is  by  illustrating  in  his 
own  person  the  successful  activity  of  this  faculty  that  the  professor  of 
natural  science  exerts  his  most  beneficent  influence  on  his  pupils. 

Judgment  renders  its  loftiest  service  when  it  deals  with  the  logical 
inductions  from  the  data.  The  first  step  logically — though  often  not 
psychologically — is  the  determination  of  the  differences  and  of  the 
resemblances  among  the  data.  Eesemblances  are  far  more  difficult  to 
recognize  than  dissimilarities  and  they  are  often  as  non-existent  to  un- 
trained minds.  Then  follow  the  proper  reasoning  processes  which,  if 
successful,  carry  us  beyond  the  observations  to  the  generalization,  which 
makes  part  of  the  growth  of  science. 

Now  the  nearer  a  practitioner  of  medicine  comes  to  possessing  the 
gift  of  observation,  as  just  described,  the  better  practitioner  he  will  be ; 
and,  inasmuch  as  it  is  only  in  science  that  such  ideals  of  observation 
are  maintained,  it  is  evident  that  a  scientific  training  is  indispensable 
to  produce  physicians  psychologically  fit.     One  still  sometimes  hears 


284  MEDICAL   BESEABCH   AND   EDUCATION 

the  distinction  drawn  between  the  "practical"  and  the  "scientific" 
doctor;  so  far  as  I  know,  the  most  important  difference  between  a 
"  practical "  doctor  and  the  truly  scientific  is  that  the  patients  of  the 
former  are  the  more  likely  to  die.  Yet,  of  course,  practical  experience 
is  of  the  utmost  professional  importance.  Medicine  is  one  application — • 
only  one  of  many — of  biologic  knowledge  to  practical  needs,  and  the 
practical  technic  of  the  application  must  be  mastered.  There  are  useful 
practitioners  of  medicine  whose  utility  is  founded  on  their  practical 
experience,  but  I  had  rather  entrust  myself  to  the  care  of  one  who  had 
in  addition  to  a  practical  technical  mastery  a  mind  educated  to  observe 
with  scientific  accuracy  and  reason  with  scientific  precision.  Those 
who  extol  the  practical  man  and  decry  the  scientific  are  of  the  sort  who 
would  rank  plumbers  above  engineers. 

St.  Louis  has  had  two  physicians  to  whom  I  wish  specially  to  allude, 
because  they  possessed  the  noble  spirit  of  research  to  a  preeminent 
degree.     Their  memories  are  held  in  honor  wherever  biologic  science 
has  a  foothold.     Both  owe  their  well-earned  reputations  to  their  ability 
as  scientific  observers ;  Beaumont  and  Engelmann  were  practitioners,  but 
their  investigations  demonstrate  that  they  realized  in  their  own  persons 
the  ideal  we  have  before  us.     Their  work  has  added  an  enduring  luster 
to  the  fame  of  St.  Louis.     May  they  have  many  worthy  successors ! 
-i  \     The  second  quality,  which  both  the  medical  student  and  the  gradu- 
ated physician  must  possess,  is,  at  least  in  my  opinion,  intellectual 
endurance.     The  medical  mind  must  work  not  only  well,  but  strenu- 
ously and  continuously.    The  period  of  study  in  America  is  now  actu- 
ally from  six  to  eight  years,  since  four  years  has  become  the  standard  of 
the  medical  schools,  and  admission  to  them  demands  one  or  two  years' 
work  in  the  preliminary  sciences,  to  all  which  a  year  or  two  in  the  hos- 
pital ought  to  be  added.    During  every  one  of  these  years  the  student 
must  work  at  high  pressure,  mastering  one  branch  of  science  after 
another,  learning  the  general  principles,  the  technical  methods  and  the 
practical  applications  of  each,  and  gradually  fitting  himself  for  the  art 
of  practise.     Having  accomplished  so  much,  he  can  not  for  an  instant 
relax  his  acquisition  of  further  knowledge,  not  merely  from  his  own 
direct  experience  of  diseased  persons,  but  also  by  keeping  abreast  all  his 
life  with  the  progress  of  medicine.    He  must  keep  up  not  only  with  the 
improvements   in  medical   treatment,  but  also   with   the  advance  of 
scientific  knowledge.     To  do  this  perfectly  has  already  become  impos- 


IDEALS    OF    MEDICAL    EDUCATION  285 

sible,  and  the  difficulty  is  constantly  increasing.  The  older  practitioner 
as  he  becomes  busier,  and  his  years  render  new  modes  of  thought  more 
difficult  for  him,  must  lag  more  and  more  behind  the  times  and  feel 
himself  less  and  less  well  equipped  than  the  oncoming  young  man.  He 
is  saved  from  discard  only  by  his  ripened  judgment  and  his  wisdom  in 
dealing  with  patients.  It  is  evident  that  intellectual  endurance,  a  sus- 
tained mental  power,  an  ever-active  gift  of  apprehension,  a  ceaseless 
passion  for  knowing — call  it  what  you  will — is  demanded  of  the  mem- 
bers of  the  medical  profession  as  of  no  other.  Medicine  is  a  profession  ^^ 
which  only  men  of  exceptional  ability  should  enter.  Men  of  moderate 
gifts  should  seek  other  occupations.  In  the  future,  as  medical  knowl- 
edge becomes  still  more  vast,  high  ability  will  be  indispensable  for 
those  who  try  to  master  and  apply  it.  No  other  profession  is  likely  to 
equal  it  in  difficulty,  for  the  law}'^ers,  engineers,  architects,  chemists 
and  others  have  far  less  complicated  problems  than  the  physician;  and 
their  fields  of  knowledge  are  smaller.  Moreover,  specialization  in  the 
learned  professions  mentioned  is  far  more  feasible  than  in  medicine, 
for  every  part  of  our  bodies  is  related  so  intimately  to  every  other  part 
that  no  specialist  can  deal  with  his  subject  as  an  isolated  field  of  prac- 
tise. Not  merely  as  in  all  scientific  professions  must  a  man  keep  up 
with  the  general  progress  of  knowledge,  but,  since  every  organ  is 
related  physiologically  and  pathologically  to  every  other,  the  medical 
specialist  can  not  seclude  himself  in  his  chosen  subject,  but  must  pre- 
serve his  active  intercourse  with  all  medical  domains.  The  practitioner, 
no  matter  how  much  absorbed  in  work,  must  remain  all  his  life  a  quick, 
diligent,  alert,  receptive  learner.  Never  may  he  let  himself  feel  a 
senescent  apathy  to  new  ideas.  The  ideal  physician  possesses  a  life- 
long intellectual  endurance. 

The  psychologic  traits  desirable  in  members  of  the  medical  profes- 
sion are  many  and  complex.  Even  were  I  competent  to  review  and 
discuss  them  all,  such  a  disquisition  would  not  suit  this  occasion,  and  it 
will  suffice  to  keep  our  attention  concentrated  on  a  few  fundamentals. 
Let  us,  therefore,  content  ourselves  with  adding  loyalty  as  the  third 
indispensable  quality,  for  loyalty  best  expresses  that  quality  of  single- 
minded  devotion,  that  trinity  of  faithfulness  to  occupation,  to  purpose 
and  to  person  which  makes  us  gratefully  reverence  the  great  physician. 
Loyalty  is  a  natural  gift,  but,  like  all  natural  endowments  of  character, 
it  may  be  cultivated,  trained  and  strengthened.     Our  entering  students 


286  MEDICAL   BESEABCE   AND   EDUCATION 

rapidly  classify  themselves  according  to  their  loyalty  to  their  immediate 
work.  The  best  men  already  feel  the  gravity  of  their  decision  to  become 
physicians;  they  appreciate  the  seriousness  of  their  studies,  and  work 
faithfully  each  day  with  a  prophetic  instinct  that  each  day's  knowledge 
builds  up  the  base  for  their  future  decisions.  They  are  already  filled 
with  a  sense  of  responsibility ;  and  to  nourish  that  sense,  to  sustain  the 
loyalty  of  the  learners  should  be  the  constant  goal  of  the  medical 
teachers'  ambition.  The  student  should  be  made  to  feel  from  the  very 
start  that  his  purpose  in  life  must  be  to  serve,  and  that  devotion  to  his 
studies  is  his  initiation  into  the  life  of  perfect  devotion  to  his  patients. 

Eequirements  for  a  Good  Medical  Student 

The  man  who  purposes  to  study  medicine  should  have  in  high 
degree  three  gifts,  not  one  of  which  is  common  among  mankind,  yet  all 
of  which  he  must  have.  The  three  gifts  are :  the  power  of  reliable  obser- 
vation, intellectual  endurance,  loyalty. 

If  the  estimate  we  have  made  of  the  needed  capacities  of  a  physician 
be  correct,  it  follows  that  a  good  medical  school  can  exist  only  with  good 
students.  Coins  of  full  value  can  not  be  made  of  impure  metal. 
We  must,  therefore,  start  with  the  consideration  of  the  means  to 
select  students  to  the  exclusion  not  merely  of  the  bad  ones,  but  also 
of  the  mediocre.  We  must  not  attempt  to  mint  doctors  from  merit 
basely  alloyed.  Examinations  should  have  their  main  use,  not  as  a 
means  of  admission,  but  as  a  means  of  exclusion,  and  the  more  men  of 
low  and  middle  rank  that  are  excluded  the  better.  One  poor  student 
damages  a  whole  class.  We  should  look  forward  to  the  exclusion  of  all 
men  who  fail  to  get  high  marks  in  the  preliminary  tests,  so  that  there 
may  be  a  reasonable  probability  that  all  who  get  in  are  capable  of  hard 
sustained  mental  work  and  of  loyalty  to  their  studies.  The  examina- 
tions ought,  however,  to  accomplish  more  than  this :  they  should  afford 
evidence  that  the  candidate  has  a  natural  power  of  observation,  and 
that  the  power  has  already  received  some  scientific  discipline,  and, 
finally,  they  ought  to  prove  that  the  candidate  has  the  preliminary 
knowledge  of  chemistry,  physics  and  general  biology  without  which  the 
pursuit  of  the  medical  sciences  is  impossible.  It  is  a  welcome  sign  of 
progress  that  these  entrance  requirements  are  being  rapidly  adopted  by 
the  medical  schools  of  the  country,  and  there  is,  I  am  glad  to  perceive, 
a  steady  advance  toward  uniformity.     In  my  opinion,  such  a  prelimi- 


IDEALS    OF    MEDICAL    EDUCATION  287 

nary  training,  with  the  appropriate  sifting  of  the  unfit,  can  be  accom- 
plished by  two  or  three  years  of  college  work — and  it  is  not  and  can  not 
be  accomplished  by  requiring  an  A.B.  degree  (or  its  equivalent)  unless 
that  degree  represents  adequate  courses  in  chemistry,  physics,  biology, 
French  and  German.  Under  the  prevalent  elective  system,  a  man  may 
become  a  bachelor  of  arts  and  yet  be  not  only  undisciplined,  but  also 
very  ignorant  of  natural  science.  I  have  had  to  do  with  many  such 
men,  and  can  only  say  that  they  are  so  inferior  at  the  start  that  only 
the  most  brilliant  of  them  can  overcome  the  heavy  handicap.  Indeed, 
I  can  not  affirm  that  even  the  brilliant  men  are  able  wholly  to  repair  the 
evil,  for  in  the  rush  of  medical  study  they  have  no  time  to  make  up 
their  deficiencies  in  the  preliminary  sciences.  They  enter  as  cripples 
and  as  cripples  still  they  are  likely  to  graduate  from  the  medical  school. 
Although  observation  is  the  foundation  of  knowledge,  and  no  human 
knowledge  is  built  on  any  other  foundation,  men  of  intellectual  power 
are  by  no  means  always  interested  in  observation.  There  are  mathe- 
maticians who  can  scarcely  be  said  to  feel  interest  in  any  observations. 
I  often  recall  with  amusement  a  distinguished  mathematician  whom  I 
would  not  have  trusted  to  make  an  original  observation  beyond  a 
simple  measurement,  and  yet  who  condescendingly  explained  to  a  com- 
pany of  biologists  that  their  science  must  remain  inaccurate  until  its 
results  were  mathematically  formulated.  The  reply  might  have  been 
made  to  him  that  no  mathematical  result  can  be  accurately  known  until 
put  in  graphic  form,  so  that  it  can  be  observed.  The  one  half-truth  is 
as  good  as  the  other.  Our  mathematical  friend  had  still  to  learn  that 
there  is  an  accuracy  in  a  complex  visual  image  with  which  mathematics 
can  not  even  distantly  vie.  "We  might  construct  a  scale,  with  the 
anatomist  at  one  end  and  the  mathematician  at  the  other;  both  alike 
depend  on  observation,  but  one  seeks  his  accuracy  chiefly  in  the  renewal 
and  extension  of  his  personal  observations — he  loves  first-hand  knowl- 
edge; the  other  seeks  his  accuracy  in  the  logical  evolution  of  quantita- 
tive relations,  and  cares  but  little  for  the  simple  observations  on  which 
his  mathematics  depends.  Between  these  two  extremes  we  must  range 
those  minds  which  enjoy  and  seek  both  observational  and  logical  satis- 
faction, and  who  are  often  experimenters.  Among  experimenters  there 
is  a  wide  range  in  the  degree  of  relative  interest — on  the  one  hand,  in 
what  can  be  directly  observed,  and,  on  the  other,  in  the  logical  work 
following  the  experiment.    Only  those  in  whom  the  love  of  observation 


288  MEDICAL   BESEABCH   AND   EDUCATION 

is  predominant  are  likely  to  succeed  as  physicians.  For  the  pure 
experimenter  there  is  plenty  of  room  in  medical  science,  but  he  can 
hardly  find  his  right  opportunity  in  medical  practise. 

The  natural  observer  differs  both  from  those  who,  like  the  humani- 
tarians, are  satisfied  by  second-hand  knowledge,  and  from  those  who 
prefer  experimental  work,  by  his  insatiable  craving  for  seeing,  and,  to  a 
less  extent,  for  hearing  and  feeling.  His  inborn  need  is  to  have  direct 
contact  with  the  phenomena.  Nothing  short  of  the  personal  acquaint- 
ance with  the  phenomena  satisfies  him.  Now  those  students  who  while 
in  college  elect  the  humanitarian  studies,  and  neglect  the  natural 
sciences,  are  extremely  unlikely  to  have  the  observing  faculty.  If  they 
are  required  to  study  chemistry,  physics  and  biology  before  they  get  to 
medical  work  they  will  be  tried  out,  and  those  who  have  not  the 
observer's  gift  will  learn  their  limitations  in  time  to  avoid  becoming 
medical  impedimenta. 

The  Standaeds  for  the  Medical  School 

Having  obtained  our  students,  we  ask  next:  "What  shall  we  teach 
them  ?  "  Eeally  good  answers  to  this  question  are  given  by  the  curricula 
of  our  better  schools,  which  differ  from  one  another  only  in  detail,  since 
in  all  the  subjects  are  the  same  and  the  order  in  which  they  follow  is 
essentially  fixed. 

Two  comments  on  the  present  typical  medical  curriculum  may  be 
ventured:  too  much  time  is  devoted  to  lectures,  too  little  time  to 
physiology.  It  is,  if  I  be  not  mistaken,  universally  true  that  in  Amer- 
ican medical  schools  a  large  number  of  lectures  are  given  which  are 
mere  repetitions  of  what  is  often  better  expounded  in  the  text-book. 
It  would,  in  my  opinion,  be  wiser  to  devote  many  of  the  hours  now  used 
for  lectures  to  practical  work,  restricting  the  lectures  to  general  prin- 
ciples, the  elucidation  of  complicated  subjects,  especially  those  which 
can  be  made  clear  by  verbal  explanation  combined  with  drawings, 
models  or  experiments.  Lectures  at  best  can  convey  very  little  actual 
information,  and  their  greatest  usefulness  is  in  exhibiting  to  the  stu- 
dents the  point  of  view,  the  intellectual  attitude  of  the  professor,  who 
is  not  fit  for  his  position  unless  his  mental  work  is  better  than  that  of 
any  of  his  students.  The  outlook  in  America  is  full  of  encouragement. 
Nowhere  else  in  the  world  has  laboratory  instruction  advanced  as  far 
and  well  as  in  this  country.    Germany  must  look  to  her  laurels,  for  the 


IDEALS    OF    MEDICAL    EDUCATION  289 

whole  university  tradition  there  exalts  the  lecture.  The  system  is 
strongly  entrenched,  for  the  professors  depend  on  lecture  fees.  The 
future  of  scientific  education  depends  on  laboratories,  and  unless  Euro- 
pean universities  imitate  the  American  laboratory  standards  the  stream 
of  students  from  Europe  to  the  United  States  will  soon  be  greater  than 
that  of  a  generation  ago  from  our  country  to  Germany. 

As  regards  physiology,  have  we  not  to  deplore  the  fact  that  very  few 
physicians  think  physiologically?  It  is  only  too  true  that  if  a  practi- 
tioner is  asked  for  a  physiologic  explanation,  his  answer  is  usually  so  lame 
that  it  can  scarcely  be  said  to  go.  Ask  an  oculist  why  the  tears  run  on  a  cold 
day ;  or  a  clinician  the  cause  of  pain  from  indigestion,  or  how  opium  works, 
or  what  is  the  physiologic  basis  of  shock;  ask  a  gynecologist  why  birth 
occurs;  ask  a  general  practitioner  the  cause  of  senescence;  or  ask  a 
surgeon  how  the  after-effects  of  ether  are  caused — and  the  answer  is 
likely  to  be  by  no  means  in  physiologic  terms,  by  no  means  an  analysis 
of  functions,  but  rather  an  empirical  statement;  and  a  physiologist 
listening  might  well  feel  himself  transported  to  the  middle  ages.  The 
body  is  a  functioning  machine,  and  when  it  does  not  work  properly  it 
ought  not  to  be  tinkered  by  empiricists  working  by  rules,  but  examined 
and  repaired  by  physicians,  whose  chief  claim  to  confidence  is  that 
they  are  expert  physiologists,  whose  knowledge  of  the  bodily  functions 
guides  their  practise.  I  deem  the  opinion  sound  which  regards  physiol- 
ogy as  the  central  discipline  of  medicine,  and  maintains  that  a  generous 
development  of  clinical  physiology  is  the  improvement  needed  above  all 
others  in  our  medical  curriculum.  We  are  all  agreed  as  to  the  impor- 
tance of  anatomy  in  medical  education — it  can  hardly  be  exaggerated — 
nevertheless,  we  may  feel  tempted  to  say  that  physiology  is  even  more 
important. 

In  regard,  however,  to  material  resources,  our  schools  differ  widely ; 
and  those  which  suffer  from  deficient  laboratories  must  either  make  up 
their  deficiencies  or  go  under,  drowned  in  the  flood  of  the  progress  of 
the  others.  We  have  in  America  to-day  a  number  of  laboratories  at 
various  medical  schools  which  are  serving  as  present  standards.  All 
the  best  teaching  in  the  medical  sciences  is  laboratory  teaching.  Each 
one  of  the  sciences  must  have  a  large  and  expensively  equipped  building. 
The  building  must  afford  a  separate  work-place  for  every  individual 
student,  rooms  for  the  staff,  rooms  for  advanced  students  and  research ; 
a  lecture  hall,  library,  and  other  necessary  conveniences.     These  are 

20 


290  MEDICAL   EESEABCH    AND    EDUCATION 

merely  minimum  requirements,  and  mean  that  the  cost  of  the  plant 
for  a  respectable  medical  school  is  not  to  be  reckoned  by  thousands,  but 
by  millions  of  dollars.  There  is  no  choice.  Those  responsible  for  the 
financial  management  may  be  staggered  by  the  demands  of  their 
medical  faculty;  they  may  be  able  to  meet  the  demands  only  partially 
for  the  time  being,  but  in  a  comparatively  few  years  from  now  only 
those  medical  schools  will  be  found  surviving  which  have  met  these 
demands.  With  time,  too,  the  demands  are  sure  to  become  more  insist- 
ent and  more  numerous.  Never  have  the  financial  responsibilities 
been  so  great,  but,  I  repeat,  there  is  no  choice.  The  laboratory  educa- 
tion is  our  one  sure  foundation.  It  is  indispensable  that  it  be  amply 
provided  for;  if  that  can  not  be,  the  failure  ought  to  be  acknowledged 
and  the  school  closed. 

It  is  in  the  laboratories — and  only  in  them — that  the  power  of 
observation  can  be  disciplined  and  developed,  and  only  in  them  that 
the  students  can  acquire  genuine  knowledge.  In  speaking  thus,  we 
class  the  hospital  with  the  laboratory.  It  is  my  belief,  strongly  held, 
that  a  laboratory  is  an  efficient  influence  only  when  it  is  a  place  where 
original  research  goes  on  actively.  While  it  is  true  that  the  informa- 
tional purpose  gl^ides  the  daily  labor,  and  that  it  is  indispensable  that 
the  student  make  by  observation  personal  acquaintance  with  as  many 
phenomena  as  practicable,  yet  it  remains  also  true  that  the  student 
should  find  in  the  laboratory  an  ideal  standard  of  work — and  the  only 
possible  high  ideal  is  that  of  original  investigation.  It  is  relatively 
easy,  under  the  guidance  of  an  experienced  instructor,  with  materials 
carefully  prepared  beforehand,  to  confirm  by  actual  observation  the 
statements  of  the  text-book. 

No  doubt  one  exclusively  so  trained  can  become  a  useful  mediocrity 
among  practitioners;  no  doubt,  even,  that  gifted  men  so  trained  will 
forge  ahead  despite  the  training;  yet  certainly  a  better  education  is 
secured  when  the  students  acquire  appreciation  of  productive  scholar- 
ship, and  feel  themselves  so  near  it  that  it  is  an  actual  and  living 
interest  to  them.  Old  discoveries  do  not  stir  much.  We  read  calmly 
that  some  fact,  which  we  find  stated  in  all  the  text-books  as  familiar  to 
everybody,  was  discovered  fifty  or  forty  or  two  hundred  years  ago  by  a 
man  whose  name  awakens  no  significant  associations.  Utterly  different 
is  the  effect  on  the  student's  mind  when  he  learns  that  his  instructor 
has  made  a  successful  research  and  has  new  discoveries  to  report.    It  is 


IDEALS    OF    MEDICAL    EDUCATION  291 

inspiring  to  him  to  know  the  discoverer.  He  feels  himself  a  witness  of 
the  work  of  creation,  and  unconsciously  his  belief  in  the  possibility  and 
value  of  original  work  becomes  a  living  influential  conviction;  and  he 
rises  at  once  to  a  higher  intellectual  plane.  He  advances  on  his  way 
toward  becoming  a  man  of  culture — a  title  which  to-day  only  those  can 
claim  who  have  learned  to  revere  productive  scholarship. 

Let  us  never  forget  that  in  contemporary  education  the  moribund 
ideal  is  slavery  to  books ;  the  nascent  ideal,  mastery  of  facts ! 

The  consideration  of  our  needs  forces  on  us  the  conclusion  that 
medical  schools  not  only  ought  to  be,  but  must  be  centers  of  research  in 
order  to  succeed.  To  this  end  each  school  should  be  closely  allied  with 
the  postgraduate  department  of  its  university,  and  the  various  medical 
sciences  should  be  on  a  par  in  academic  standing  with  the  other  natural 
sciences.  Scientific  students  not  intending  to  become  physicians  should 
be  encouraged  to  enter  the  medical  laboratories,  and  the  highest  uni- 
versity degrees  should  be  as  open  to  students  of  anatomy,  pathology, 
bacteriology,  physiology,  etc.,  as  to  students  of  zoology,  chemistry,  or 
physics.  If  this  policy  be  adopted  with  zeal,  the  reaction  on  the  medical 
school  will  be  wholesome,  the  effect  on  the  university  at  large,  uplifting. 

The  Selection  of  the  Faculty 

We  have  passed  in  review  important  aspects  of  the  problem  of  main- 
taining a  good  medical  school,  but  the  most  important  factor  of  all,  on 
which  the  successful  solution  of  the  problem  chiefly  depends,  we  have 
not  yet  mentioned ;  it  is  the  corps  of  professors.  Is  it  reckless  to  assert 
that  no  school  has  ever  secured  a  sufficient  number  of  sufficiently  good' 
professors?  Perhaps  no  school  ever  will.  As  President  Eemsen  has 
said,  keenly  and  justly,  the  supply  of  good  professors  is  always  short. 
One  great  professor  may  leaven  a  whole  faculty,  but  the  need  is  for  a 
great  professor  at  the  head  of  the  five  principal  divisions:  anatomy, 
physiology,  pathology,  medicine  and  surgery,  and  for  first-class  men  at 
the  head  of  the  principal  specialties.  The  majority  of  American  medical 
schools  certainly  are  without  such  corps  of  leaders. 

The  prevalent  constitution  of  the  medical  faculties  is  due  to  various 
causes.  First  may  be  mentioned  the  survival  of  professors  from  an 
early  epoch  with  lower  standards;  professors  of  anatomy  who  are  not 
professional  anatomists;  of  pathology  who  are  busy  practitioners;  of 
clinical  medicine,  without  knowledge  of  modern  pathology.    This  diffi- 


292  MEDICAL   SESEABCE   AND   EDUCATION 

culty  cures  itself.  A  second  cause  is  the  custom  of  promoting  local  men, 
who  are  rewarded  with  professorships  for  their  faithfulness  rather  than 
for  their  ability.  Every  such  promotion  prevents  the  appointment  of 
an  abler  man  from  outside.  A  third  cause,  and  the  most  potent  of  all, 
is  the  American  system  of  appointment  by  the  president  and  trustees  of 
the  university,  which  often  amounts  to  appointment  by  the  president 
alone. 

The  administration  of  our  colleges  and  universities  has  become  more 
or  less  autocratic.  The  university  president  has  great  power,  which  we 
are  accustomed  to  see  liberally  employed,  on  the  whole,  to  the  immense 
advantage  of  the  university  cause.  President  Oilman's  service  to  higher 
education  has  our  fullest  admiration,  and  there  are  other  presidents  still 
living  who  are  great  leaders  and  whom  we  delight  to  honor.  We  can 
not  regret  this  phase  of  our  development,  though  there  are  many  now 
who  hope  and  believe  that  it  is  only  a  phase,  and  who  welcome  the 
unmistakable  signs  of  the  transformation  of  the  office,  by  which  the 
university  president  of  the  future  will  be  more  a  business  administrator 
and  less  a  minister  of  education.  The  president  is  likely  to  long  remain 
a  valuable — an  almost  indispensable — factor  in  our  university  life ;  but, 
in  my  opinion,  is  not  likely  to  retain  any  such  control  over  appointments 
as  he  at  present  exercises.  This  control  depends  on  the  custom  of 
liaving  appointments  made  by  the  board  of  trustees,  which  is  typically 
■composed  of  business  and  professional  men  who  are  qualified  to  advise 
^bout  the  management  of  funds,  the  conservation  of  resources  and  the 
"distribution  of  income.  The  trustees  ought,  however,  to  admit  frankly 
to  themselves  that  their  chief  usefulness  is,  first,  to  increase  the  re- 
sources of  the  university;  second,  to  determine  the  broad  questions  of 
general  policy  so  as  to  secure  a  symmetrical  growth  of  the  institution. 
It  is  inevitable  that  the  large  majority  of  them  should  be  inexpert  in 
education,  inadequate  in  their  notions  of  scholarship,  and  ignorant  of 
the  needs,  methods,  and  possibilities  of  most — if  not  all — kinds  of 
original  research.  Such  a  board  at  its  best  can  not  by  any  possibility 
be  a  very  successful  piece  of  machinery  for  the  selection  of  professors, 
because  the  members  can  not  form  a  valuable  judgment  of  their  own 
concerning  the  only  indispensable  qualification  of  a  candidate  for  a 
professorship — his  ability  to  do  original  research  of  a  high  order.  They 
forget  too  readily  and  too  often  that  it  is  a  disgrace  to  a  university  to 
appoint  a  man  as  professor  chiefly  because  he  is  a  "good  teacher" — 


IDEALS    OF    MEDICAL    EDUCATION  293 

such  a  man  may  be  a  good  school-teaclier,  but  only  investigators  can  give 
university  instruction. 

In  securing  a  faculty,  the  president  and  trustees  must  be  guided  by 
advice,  and  they  undoubtedly  are  so  guided  to  a  very  large  extent  at  the 
present  time.  But  the  advice  is  too  often  gathered  more  or  less  fortui- 
tously, and  not  by  any  definite  custom  or  fixed  principle.  For  our  future 
welfare  it  is  important  to  plan  for  obtaining  the  best  advice,  or,  in  other 
words,  to  make  sure  of  good  nominations  being  systematically  presented. 
Accordingly,  I  look  forward  to  seeing  in  the  near  future  the  task  of 
nominating  candidates  for  professorships  and  other  teaching  positions 
assigned  to  the  university  faculties. 

It  goes  without  saying  that  a  university  teacher  must  be  by  char- 
acter and  manners  fitted  to  join  a  society  of  scholars  and  to  come  into 
intimate  contact  with  young  men  and  women.  "We  can  not,  however, 
make  every  respectable  gentleman  a  professor ;  but  we  must  be  sure  that 
he  has  a  sound,  powerful,  creative  intellect,  of  which  the  only  satisfac- 
tory proof  is  original  research  of  a  high  order.  In  comparison  with  the 
possession  of  this  intellectual  gift,  all  other  endowments  are  subsidiary. 
Professors  may  vary  much  in  their  ability  to  lecture,  their  availability 
for  administrative  work,  in  their  adaptation  to  social  life,  in  their 
capacity  for  business,  in  the  quality  of  their  minds;  but  all  good  pro- 
fessors are  necessarily  alike  in  the  possession  of  creative  mental  power. 

The  selection  of  candidates  for  professorships  must,  then,  be  made 
by  persons  who  can  form  expert  judgment  on  the  original  investigations 
of  the  possible  candidates.  In  universities,  qualified  judges  are  found 
in  the  faculties — and  usually  only  in  the  faculties.  To  the  faculty, 
then,  ought  to  be  given  the  exclusive  right  of  nomination,  leaving  to  the 
trustees  only  the  right  of  confirmation;  partly  as  a  check  against 
possible  occasional  errors  of  judgment  by  the  faculty,  partly  as  a  finan- 
cial safeguard  against  expense  not  warranted  by  the  actual  resources. 
This  implies  a  radical  reform  in  our  universities;  but  until  the  time 
comes  when  teaching  appointments  can  be  initiated  only  by  faculty 
action  there  will  continue  to  be  an  unnecessarily  large  proportion  of 
more  or  less  incompetent  professors. 

Let  us  summarize  the  opinions  expressed :  A  good  medical  school 
produces  good  physicians.  The  medical  profession  is  a  very  difficult 
one,  and  to  meet  its  requirements  exceptional  men  must  receive  a 
splendid  special  training.    Therefore,  a  good  medical  school  will  accept 


294  MEDICAL   BESEABCH    AND    EDUCATION 

only  such  students  as  have  been  selected  by  severe  tests  with  high  stand- 
ards; it  will  maintain  lofty  ideals  of  knowledge,  of  observation,  of 
judgment,  of  original  thought  and  of  loyalty.  It  will  uphold  these 
ideals  not  only  by  striving  to  furnish  every  important  material  facility 
in  laboratory  and  hospital,  but  also  by  engaging  able  instructors.  The 
good  medical  school  may  become  great  which  adopts  as  its  motto : 
Great  professors  make  a  great  school.  Let  this  be  your  device,  for  the 
greater  in  ideals  and  achievement  your  school  becomes,  the  more  you 
will  help  and  inspire  all  the  other  medical  schools  in  our  country. 


THE  CAREER  OF  THE  INVESTIGATORS 

By  W.  B.  Cannox,  A.M.,  M.D., 

George  Higginson  Professor  of  Physiology,  Harvard  University 

Scarcely  more  than  a  generation  ago  the  graduate  in  medicine  had 
his  professional  career  marked  out  for  him  with  a  fair  degree  of  definite- 
ness.  Private  practise,  as  exemplified  in  the  functions  of  the  family 
physician,  offered,  apart  from  surgery,  almost  the  only  opportunity  for 
the  use  of  a  medical  training.  During  the  past  thirty  years  how  exten- 
sively have  medical  activities  become  diversified.  The  paths  of  service 
that  now  invite  the  young  physician  are  so  varied  that  every  graduate 
should  be  able  to  select  a  way  for  employing  his  peculiar  powers  to  the 
best  advantage.  Quite  apart  from  the  conventional  career  of  the  physi- 
cian, the  surgeon,  or  the  different  specialists,  are  the  opportunities  for 
usefulness  in  the  wide-spread  movements  which  are  socializing  medicine. 
In  professional  service  at  hospitals  and  sanatoriums  important  work 
can  be  done;  in  boards  of  health,  municipal,  state  and  national;  in 
public  propaganda  for  temperance,  for  the  prevention  of  infant  mor- 
tality, for  industrial  hygiene,  for  the  care  of  school  children;  in  the 
campaigns  against  tuberculosis  and  venereal  disease — in  all  these  activi- 
ties the  possibilities  of  applying  a  medical  education  usefully  to  social 
needs  are  numerous  and  are  yearly  increasing. 

Still  another  new  career  open  to  the  young  graduate  is  that  of  re- 
search in  the  medical  sciences.  For  attracting  young  men  into  scholarly 
careers  the  medical  sciences  are,  I  suspect,  at  some  disadvantage  com- 
pared with  other  natural  sciences.  Such  subjects  as  zoology,  botany 
and  physics,  for  example,  taught  in  the  colleges,  recruit  their  investi- 
gators from  students  who,  in  undergraduate  days,  before  their  life- 
purposes  are  definitely  fixed,  find  the  pure  interest  of  the  science  a 
motive  which  determines  their  whole  future.  The  medical  sciences,  on 
the  other  hand,  are  usually  presented  to  students  only  after  they  have 
decided  to  fit  themselves  for  practise  in  a  highly  attractive  profession — 
that  of  mitigating  the  physical  sufferings  of  their  fellow  men.     The 

^Address  to  the  graduating  class  of  the  Yale  Medical  School,  June,  1911. 
Published  in  Science,  July  21,  1911. 

295 


296  MEDICAL    BESEABCE    AND    EDUCATION 

medical  sciences  become  thereby  merely  a  means  to  a  particular  and  pre- 
determined end.  And  not  infrequently  the  laboratory  courses,  because 
they  defer  the  time  of  coming  into  direct  and  helpful  contact  with 
human  beings  in  need,  are  regarded  by  medical  students  with  impa- 
tience. To  men  who  take  that  attitude,  scientific  investigation,  because 
of  its  remoteness  from  the  distress  and  the  critical  struggles  of  sick  men 
and  women,  is  apt  to  seem  trifling.  Perhaps  they  look  upon  the  inves- 
tigator with  benevolent  interest,  or  as  a  teacher  they  may  like  him,  but 
they  will,  with  fair  certainty,  remain  indifferent  to  his  scholarly 
occupation. 

Because  the  attention  of  medical  students  is  fixed  so  definitely  on 
the  practise  of  their  calling  they  may  entirely  fail  to  understand  the 
nature  of  scientific  research,  the  sort  of  value  which  it  possesses,  or  the 
incentives  which  impel  men  to  its  pursuit — in  short,  they  may  remain 
quite  unaware  of  what  productive  scholarship  in  the  medical  sciences 
really  implies.  Yet  the  work  of  investigation  is  of  prime  importance  to 
medicine,  and  it  yields  some  of  life's  profoundest  satisfactions  to  the 
man  who  pursues  it.  Among  the  multiplying  opportunities  open  to 
persons  with  medical  training,  should  not  the  career  in  research  be 
better  known  and  appreciated  ?  It  offers  such  important  possibilities  of 
serving  not  only  one's  own  generation,  but  all  future  generations  as  well, 
and  it  grants  rewards  so  generously  to  those  who  embrace  it  that  I 
propose  to  discuss  with  you  some  of  its  characteristics,  and  some  of  the 
qualities  of  those  who  pursue  it  successfully. 

In  a  medical  school  as  in  other  institutions  of  technical  education 
the  emphasis  must  be  placed  on  what  has  been  confirmed  by  experience, 
on  what  is  well  knoAvn  and  established.  To  point  out  repeatedly  what 
is  not  known,  or  where  lie  the  boundaries  between  our  knowledge  and 
our  ignorance,  may  be  an  interesting  intellectual  exercise,  but  it  does  not 
alleviate  the  sufferings  of  the  sick  or  help  to  meet  any  immediate  prac- 
tical emergency.  Nevertheless,  it  is  our  ignorance  of  disease  and  its 
conditions  that  limits  absolutely  our  effective  grappling  with  many  of 
the  most  distressing  afflictions  of  mankind. 

The  investigator  is  first  of  all  one  who  thinks  as  much  of  what  we 
are  ignorant  of  as  he  does  of  what  has  already  been  made  clear.  His 
chief  interest  is  in  the  territory  which  has  not  yet  been  traversed. 
Indeed  he  is  to  be  classed  with  explorers  and  pioneers.  For  such  men 
the  complacent  contemplation  of  things  accomplished  is  intolerable — 


THE    CABEEB    OF    THE    INVESTIGATOB  297 

they  chafe  tinder  the  routine  of  established  ways,  and  find  the  satis- 
factions of  life  in  adventures  beyond  the  frontiers.  Harvey,  among  the 
first  of  modern  discoverers,  expressed  the  spirit  of  research  when  he 
wrote : 

It  were  disgraceful,  with  this  most  spacious  and  admirable  realm  of  nature 
before  us,  and  where  the  reward  ever  exceeds  the  promise,  did  we  take  the  reports 
of  others  upon  trust,  and  go  on  coining  crude  problems  out  of  these,  and  on 
them  hanging  knotty  and  captious  and  petty  disputations.  Nature  is  herself 
to  be  addressed;  the  paths  she  shows  us  are  to  be  boldly  trodden;  for  thus,  and 
whilst  we  consult  our  proper  senses,  from  inferior  advancing  to  superior  levels, 
shall  we  penetrate  at  length  into  the  heart  of  her  mystery. 

And  in  another  place  he  wrote: 

Truly  in  such  pursuit  it  is  sweet  not  merely  to  toil,  but  even  to  grow  weary, 
when  the  pains  of  discovering  are  amply  compensated  by  the  pleasures  of 
discovery. 

As  children  we  all  have  an  instinctive  curiosity  concerning  the  world 
about  us,  a  curiosity  which  most  of  us  gradually  lose  as  we  fit  ourselves 
into  the  social  conventions.  The  investigator  is  one,  however,  in  whom 
this  natural  curiosity  still  persists.  He  has  never  got  past  the  annoying 
stage  of  asking  "Why?"  The  events  occurring  on  every  side,  which 
are  matters  of  course  to  most  men,  startle  him  into  wonderment.  Why 
does  the  spinning  top  not  fall?  Why  do  animals  breathe  faster  when 
they  run  ?  Why  does  disturbed  water  take  the  form  of  waves  ?  Why  do 
roots  grown  downward?  Why  does  the  mouth  become  dry  when  one 
speaks  in  public?  Such  are  the  questions  that  arise.  The  answers  to 
them  may  be  incalculably  valuable  to  mankind.  The  microscope  re- 
vealed to  Pasteur  strange  organisms  in  bad-tasting  wines.  Why  may 
not  the  disease  of  the  wine,  he  asked  himself,  be  due  to  the  growth  of 
these  unusual  germs  within  it  ?  And  later  when  he  found  germs  also  in 
silkworms,  the  further  question  was  suggested.  Why  may  not  animals 
likewise  become  diseased  in  exactly  the  same  manner?  Whether  the 
surmises  of  the  investigator  are  true,  the  testimony  of  other  men 
usually  does  not  tell.  He  must  turn  to  nature  herself  and  put  the  idea 
to  the  test  of  observation  and  experiment. 

This  process  of  scientific  inquiry  involves  peculiar  qualifications 
which  can  not  be  disregarded  by  any  one  who  thinks  of  trying  it. 
Research  implies  in  the  first  place  seel-ing  again  over  a  region  which 
has  been  previously  traversed  in  order  to  learn  what  other  men  have 
done  and  the  point  where  their  labors  ended.     To  make  progress  sure. 


298  MEDICAL    BESEABCH    AND    EDUCATION 

therefore,  previous  records  must  be  carefully  studied.  The  failure  to 
pay  this  just  tribute  to  those  who  have  labored  before  has  not  seldom 
led  to  fruitless  effort  or  to  vain  repetition  of  work  already  well  done. 
Marking  the  boundaries  demands,  then,  a  scholarly  acquaintance  with 
earlier  discoveries;  and  the  painstaking  methods  of  the  scholar  must 
be  used. 

An  ingenious  and  inventive  imagination  is  a  second  requirement. 
It  serves  to  indicate  where  the  problems  lie  and  also  to  suggest  possible 
methods  for  solving  them.  The  mind  must  be  hospitable  to  all  ideas 
thus  presented,  and  yet  it  must  receive  them  with  skeptical  scrutiny. 
By  critically  considering  a  plan  for  solving  a  problem  it  is  often  possible 
to  select  central  tests,  which  are  strategically  related  to  the  logic  of  the 
entire  research.  The  physiologist  Goltz  is  said  to  have  done  his  most 
important  work  while  fishing,  for  he  employed  that  time  in  devising 
the  crucially  significant  experiments. 

Not  all  inquiries,  however,  can  be  ended  by  a  relatively  small  num- 
ber of  crucial  tests.  Some  investigations,  like  the  important  breeding 
experiments  of  de  Vries,  require  years  before  they  can  be  brought  to  a 
conclusion.  Patience  and  an  enthusiasm  which  is  intelligently  persist- 
ent are  therefore  essential  qualities  for  the  man  in  quest  of  new  truths. 
The  hopeful  spirit  is  especially  needed  when,  at  the  end  of  a  long  search, 
the  investigator  finds  that  he  has  only  his  labor  for  his  pains — when 
his  leading  idea  has  proved  to  be  false.  That  disheartening  event  is 
what  Huxley  called  the  tragedy  of  science — "  the  slaying  of  a  beautiful 
hypothesis  by  an  ugly  fact." 

The  very  soul  of  research,  finally,  is  the  highest  degree  of  honesty. 
The  investigator  should  see  clearly  and  accurately  with  an  eye  single  to 
the  truth.  He  has  to  consider  not  only  the  observations  which  fit  his 
theory,  but  any  others  as  well.  The  erratic  cases  invariably  make 
trouble,  but  they  are  often  disguised  blessings.  They  may  indeed  be  of 
far  greater  moment  than  those  which  have  been  anticipated,  for  they 
may  point  the  way  to  entirely  unsuspected  facts.  In  my  early  studies 
on  digestion  I  well  remember  how  much  I  was  annoyed  by  the  repeated 
failure  of  some  animals  to  show  any  signs  of  digestive  activity  during 
the  period  of  observation.  You  can  imagine  how  suddenly  my  vexation 
changed  to  deep  interest  when  the  troublesome  inhibition  was  found  to 
be  an  accompaniment  of  fright  or  anxiety  which  these  animals  showed 
while  being  looked  through  with  the  X-rays. 


TBE    CABEEB    OF    THE    INVESTIGATOB  299 

After  the  investigator  has  completed  his  examination  of  a  group  of 
questions  which  have  interested  him,  his  leading  idea,  his  tests  and  his 
results  must  be  described  with  scrupulous  exactness.  In  thus  reporting 
his  work  he  should  strive  to  be  like  clearest  crystal,  receiving  the  light 
and  transmitting  it  untinged  by  any  trace  of  color. 

Scientific  activity  implies,  of  course,  thorough  disinterestedness. 
The  investigator  asks  no  favors  and  renders  none.  Any  intimation  that 
he  act  as  a  retainer  or  special  pleader,  any  hint  or  suggestion  that  he 
restrict  his  explorations  within  certain  limits  lest  he  injure  cherished 
traditions,  is  a  step  towards  the  confinement  of  the  free  spirit  of  intel- 
lectual inquiry.  Eather  than  surrender  that  freedom  of  inquiry  or  the 
right  of  untrammeled  announcement  of  fresh  discoveries,  men  of 
science  have  in  the  past  submitted  to  tortures  and  painful  death,  and  you 
may  be  sure  that,  if  need  be,  they  will  be  ready  to  sacrifice  themselves 
again.  So  exalted  is  the  regard  in  which  the  man  of  science  holds  the 
ideal  to  which  his  life  is  devoted  that  he  would  find  in  these  words  of 
Fichte  his  solemn  pledge : 

To  this  I  am  called,  to  bear  witness  to  the  Truth.  My  life,  my  fortunes, 
are  of  little  moment;  the  results  of  my  life  are  of  infinite  moment.  I  am  a 
Priest  of  Truth;  I  am  in  her  pay;  I  have  bound  myself  to  do  all  things,  to 
venture  all  things,  to  suffer  all  things  for  her.  If  I  should  be  persecuted  and 
hated  for  her  sake,  if  I  should  even  meet  death  in  her  service,  what  wonderful 
thing  is  it  I  shall  have  done — what  but  that  which  I  clearly  ought  to  do? 

The  satisfactions  of  a  life  devoted  to  investigation,  like  the  satisfac- 
tions of  other  careers,  arise  from  the  profitable  use  of  one's  powers. 
The  peculiar  powers  which  are  needed  for  research  I  have  just  described. 
The  employment  of  these  powers  in  perfect  freedom,  and  the  immeas- 
urably important  results  that  flow  therefrom,  render  the  satisfactions  of 
productive  scholarship  especially  keen.  These  satisfactions  we  may 
now  consider  in  relation  to  the  special  qualifications  of  the  investigator. 

The  requirement  that  the  investigator  learn  what  other  men  have 
done  before  him  in  the  field  he  seeks  to  enlarge  gives  him  an  unusual 
realization  of  the  part  he  may  be  playing  in  the  promotion  of  natural 
knowledge.  Knowledge  grows  like  the  picture  in  the  dissected  puzzle. 
Every  addition  must  fit  the  parts  already  arranged  in  order  to  possess 
significance,  and  also  every  addition  makes  possible  the  fitting  of  new 
parts  whose  positions  in  the  enlarging  picture  become  thereby  suddenly 
revealed.  One  of  the  delights  of  research,  therefore,  is  the  sense  that 
every  bit  of  new  knowledge  finds  its  place  in  the  structure  of  truth,  and 


300  MEDICAL   BESEABCH   AND    EDUCATION 

that  sooner  or  later  it  will  be  required  for  the  further  building  of  that 
structure.  The  relation  which  the  fresh  contribution  bears  to  that 
already  established,  the  discoverer  clearly  sees ;  what  relation  it  will  cer- 
tainly bear  to  further  contributions  he  may  never  know.  How  little  did 
the  men  who  studied  the  minute  differences  among  mosquitoes,  and 
who  recorded  the  breeding  habits  of  those  insects  realize  their  important 
role  in  abolishing  the  pestilence  of  yellow  fever,  and  in  bringing  about 
the  immense  social  and  political  changes  which  will  result  from  that 
conquest. 

Because  every  discovery  becomes  the  basis  for  further  discovery  the 
imagination  of  the  investigator  is  constantly  stimulated.  New  facts 
suggest  in  turn  other  facts  and  point  to  unsuspected  relations  between 
things  that  have  long  been  known.  Bayliss  and  Starling's  discovery  of 
a  natural  chemical  stimulant  which  induces  secretion  of  the  pancreas 
led  directly  to  the  explanation  of  continued  gastric  secretion,  and  also 
to  finding  the  marvelous  mechanism  by  which  the  mammary  glands  are 
prepared  for  the  giving  of  milk.  Thus,  though  the  interests  of  the  man 
of  science  seem  at  the  moment  narrow  and  restricted,  they  may  never- 
theless lead  his  thought  out  into  many  diverse  realms  of  knowledge. 
These  excursions  of  the  imagination  offer  repeated  suggestions  for  fresh 
adventure.  The  look  therefore  is  always  forward  to  what  may  be  seen 
when  the  next  step  is  taken.  Seeking  new  things  becomes  in  time  a 
fixed  habit.  Past  achievements  neither  satisfy  interest  nor  hold  atten- 
tion— they  become  fused  with  the  established  routine  from  which  it  is 
a  happiness  to  escape.  The  chance  of  beholding  unsuspected  wonders, 
or  the  possibility  of  finding  that  something  imagined  is  really  true  is  a 
constant  incitement  to  further  search  and  furnishes  the  zest  and  interest 
which  are  among  the  best  rewards  of  the  investigator. 

Much  happiness  is  found  also  in  that  single-mindedness  which, 
as  we  have  seen,  is  one  of  the  prime  conditions  in  the  pursuit  of  knowl- 
edge. It  implies  freedom  from  bigotry  and  prejudice,  freedom  from 
many  of  the  influences  and  motives  that  to  their  regret  men  feel  com- 
pelled to  respect  for  purposes  of  prudence  or  policy.  The  intrusion  of 
any  other  motive,  save  that  of  discovering  and  telling  the  truth,  only 
tends  to  distract  the  mind  of  the  investigator  from  his  absorbing  work. 
Faraday,  whose  life  as  a  man  of  science  was  near  perfection,  wrote : 

Do  not  many  fail  because  they  look  rather  to  the  renown  to  be  acquired 
than  to  the  pure  acquisition  of  knowledge  and  the  delight  which  the  contented 
mind  has  in  acquiring  it  for  its  own  sake?     I  am  sture  I  have  seen  many  who 


eio 


TBE    CABEEB    OF    THE    INVESTIGATOB  301 

would  have  been  good  and  successful  pursuers  of  science  and  have  gained  them- 
selves a  high  name,  but  that  it  was  the  name  and  the  reward  they  were  always 
looking  forward  to — the  reward  of  the  world's  praise.  In  such  there  is  always 
a  shade  of  envy  or  regret  over  their  minds,  and  I  can  not  imagine  a  man  making 
discoveries  in  science  under  these  feelings. 

Single-mindedness  involves  also  a  relative  indifference  to  those 
motives  of  money-getting  whicli  prevail  in  commercial  life.  Success  in 
research  is  fortunately  not  measured  by  money  standards.  And  yet 
research  flourishes  best  where  there  is  free  time  to  spend  in  thought  and 
experiment.  This  time  element  is  essential.  The  investigator  may  be 
made  to  dwell  in  a  garret,  he  may  be  forced  to  live  on  crusts  and  wear 
dilapidated  clothes,  he  may  be  deprived  of  social  recognition,  but  if  he 
has  time,  he  can  steadfastly  devote  himself  to  research.  Take  away  his 
free  time,  and  he  is  utterly  destroyed  as  a  contributor  to  knowledge. 
Free  time  and  absence  of  the  money  motive,  however,  are  found  together 
only  among  the  indolent  poor  and  the  indolent  rich ;  and  the  observation 
has  been  made  that  neither  of  these  classes  is  likely  to  contribute  men 
of  science.  The  industry  of  the  investigator  which  results  in  new 
knowledge — knowledge  in  its  unprofitable  infancy — does  not  possess 
commercial  value.  Until  recently  indeed  any  money  value  of  research 
had  not  been  recognized.  In  the  unappreciative  past  deplorable  in- 
stances were  known  of  struggles  with  poverty  and  want,  going  hand  in 
hand  with  persistent  loyalty  to  truth-seeking,  Now,  however,  accu- 
mulated wealth  is  giving  leisure  for  men  to  carry  on  their  investigations 
free  from  the  worries  of  uncertain  livelihood.  What  they  receive  may 
not  be  much,  but  it  is  sufficient  to  permit  them  to  look  upon  the 
scramble  for  wealth  without  envy  or  regret. 

Fortunately,  the  provisions  which  enable  men  to  pursue  careers  in 
science  are  found  mainly  in  great  universities,  through  which  a  stream 
of  youth  is  constantly  passing.  There  men  who  are  moved  by  the 
instinct  of  investigation  usually  find  their  most  congenial  surroundings. 
Freedom  of  inquiry  is  the  ancient  tradition  of  the  university  spirit, 
leisure  is  recognized  as  a  requisite  for  meditative  observation,  and  the 
youth  who  resort  to  these  centers  of  learning  can  be  awakened  to 
wonder  at  nature's  hidden  secrets,  and  can  be  stimulated  to  undertake 
with  ardor  the  struggle  to  possess  them.  The  peculiar  richness  of  uni- 
versity life  flows  from  memories  of  the  transforming  powers  of  the  pro- 
gressive and  original  minds  who  have  by  their  eagerness  for  the  truth  and 
their  freedom  from  worldliness  inspired  their  students  with  their  own 
ideals. 


302  MEDICAL   EESEABCE   AND   EDUCATION 

The  greatest  compensation,  after  all,  for  the  truth  seeker  is  the 
discovery  of  the  truth.  The  value  of  labor  that  brings  a  revelation  of 
new  knowledge  does  not  cease  with  the  day ;  it  remains  as  a  permanent 
acquisition  for  the  race.  There  is  really  great  satisfaction  to  the  inves- 
tigator in  this  thought  of  the  "  durable  results  of  the  perishable  years." 
But  not  only  because  of  the  permanence  of  truth  is  there  pleasure  in 
discovery — it  is  the  marvel  of  beholding  for  the  first  time  an  unknown 
aspect  of  nature  that  fascinates  men  of  science,  and  through  difficulties 
and  repeated  disappointments  holds  them  to  the  search.  Only  he  who 
has  had  the  experience  knows  the  thrill  that  comes  when  that  which  was 
imagined  proves  to  be  true.  One  who  was  in  Faraday's  laboratory  when 
the  influence  of  the  earth's  magnetism  on  a  wire  conducting  an  electric 
current  was  first  tested,  has  written :  "  All  at  once  Faraday  exclaimed, 
'  Do  you  see,  do  you  see,  do  you  see !'  as  the  wire  began  to  revolve,  and 
I  shall  never  forget  the  enthusiasm  expressed  in  his  face  and  the  spark- 
ling in  his  eyes."  Kepler  knew  the  joy  which  rewards  the  scientific 
discoverer  when  he  completed  the  evidence  that  established  his  third 
law  of  planetary  motion.  Even  one  whose  pulses  have  not  quickened 
with  the  excitement  of  discovery  can  understand  perhaps  how  he  must 
have  felt  as  he  burst  into  triumphant  exultation : 

What  I  prophesied  two-and-twenty  years  ago,  .  ."  .  what  sixteen  years  ago 
I  urged  as  a  thing  to  be  sought,  .  .  .  that  for  which  I  devoted  the  best  part 
of  my  life  to  astronomical  contemplations,  at  length  I  have  brought  to  light 
and  recognized  its  truth  beyond  my  most  sanguine  expectations.  It  is  not  eight- 
een months  since  I  got  the  first  glimpse  of  light,  three  months  since  tlie  dawn, 
very  few  days  since  the  unveiled  sun  burst  upon  me.  Nothing  holds  me;  I  will 
indulge  my  sacred  fury.  If  you  forgive  me,  I  rejoice;  if  you  are  angry,  I  can 
bear  it.  The  die  is  cast,  the  book  is  written,  to  be  read  either  now  or  by  pos- 
terity, I  care  not  which.  It  may  well  wait  a  century  for  a  reader,  as  God  has 
waited  six  thousand  years  for  an  observer. 

The  scientific  investigator  may  not  seek  particularly  for  knowledge 
which  can  meet  at  once  some  material  need.  Like  the  artist,  he  is  more 
prone  to  direct  his  efforts  towards  that  which  will  for  the  moment 
properly  gratify  an  absorbing  interest  of  his  mind.  If  the  new  knowl- 
edge has,  when  discovered,  an  immediate  practical  value,  so  much  the 
better;  but  the  direct  search  for  understanding  has  certainly  always 
proved  the  most  effective  motive  in  scientific  labors.  Because  of  this 
attitude  the  investigator  should  not  be  regarded  as  self-centered,  or 
neglectful  of  duties  to  the  general  good.  He  is  serving  best  his  own 
generation  in  so  far  as  he  makes  his  standard  of  work  thorough  and 


THE    CABEEB    OF    THE    INVESTIGATOR  303 

honest.  In  so  far  as  he  does  that,  he  is  serving  best  future  generations 
as  well,  for  only  thus  can  the  results  of  his  work  be  used  later  as  a  basis 
for  further  advancement.  And  since  the  interrelations  of  phenomena 
are  so  manifold  the  conviction  is  justified  that  every  bit  of  honest  work 
can  finally  be  utilized  in  forming  the  body  of  truth.  Although  the 
investigator  may  labor,  therefore,  primarily  to  satisfy  his  own  curiosity, 
and  to  secure  for  his  craftsmanship  that  inner  approval  sought  by  every 
conscientious  worker,  nevertheless  he  is  making  permanent  additions  to 
the  world's  values.    There  is  about  his  life,  as  Professor  Eoyce  has  noted, 

an  element  of  noble  play.  .  .  .  One  plays  with  silk  and  glass  and  amber,  with 
kites  that  one  flies  beneath  thunder-clouds,  with  frog  legs  and  with  acid.  The 
play  is  a  mere  expression  of  a  curiosity  which  former  centuries  might  have  called 
idle.  But  the  result  of  this  play  re-creates  an  industrial  world.  And  so  it  is 
everywhere  with  our  deeper  curiosity.  There  is  a  sense  in  which  it  is  all  super- 
fluous. Its  immediate  results  seem  but  vanity.  One  could  surely  live  without 
them,  yet  for  the  future  and  for  the  spiritual  life  of  mankind,  these  results  are 
destined  to  become  of  vast  import. 

Sometimes  the  worker  in  science  lives  to  see  his  services  used  for  the 
relief  of  human  need.  When  Davy's  studies  of  combustion  enabled  him 
to  invent  the  safety  lamp,  he  gave  the  invention  freely  to  the  world.  He 
knew  then  that  thenceforth  for  all  time  toilers  in  the  mines  could  pro- 
tect themselves  against  the  dangers  of  destruction.  There  is  no  realm, 
however,  in  which  the  deep  satisfaction  of  seeing  discovery  applied  to 
human  service  is  more  likely  to  be  experienced  than  in  the  realm  of 
medical  research.  Consider  how  great  must  have  been  the  joy  of 
Pasteur  and  of  Lister  when  they  realized  that  the  consequences  of  their 
investigations  must  lessen  forever  plague  and  pestilence  and  pain  in 
men,  and  in  the  lower  animals  as  well,  and  must  permanently  remove 
much  of  the  blind  struggle  against  mysterious  agencies  of  disease  and 
death.  The  letter  which  Walter  Eeed  wrote  to  his  wife  on  New  Year's 
eve,  1900,  at  the  end  of  his  experiments  on  the  transmission  of  yellow 
fever,  tells  something  of  the  joy  of  such  service — "  The  prayer  that  has 
been  mine  for  twenty  years,"  he  concludes,  "  that  I  might  be  permitted 
in  some  way  or  at  some  time  to  do  something  to  alleviate  human 
suffering,  has  been  granted !  A  thousand  Happy  New  Years."  And  a 
thousand  happy  new  years  there  will  be  for  thousands  of  men  and 
women  and  children,  because  of  that  one  research  in  Cuba.  ^ 

Through  the  employment  of  methods  of  scientific  inquiry  to  medicar 
problems  more  progress  has  been  made  during  the  past  sixty  years 
towards  an  understanding  of  the  nature  of  diseases  and  their  control 


304  MEDICAL   BESEAECH   AND   EDUCATION 

than  had  been  made  in  the  previous  twenty-three  centuries.  Think  for 
a  moment  of  what  has  been  learned  about  diphtheria  and  tetanus,  about 
meningitis  and  rabies,  about  tuberculosis  and  syphilis,  about  dysentery 
and  cholera  and  typhoid  fever.  How  fundamentally  our  attitude  toward 
these  diseases  has  altered  as  the  discoveries  of  medical  investigators 
have  given  us  insight  and  powers  to  control.  What  great  progress  we 
have  already  made  in  this  relatively  short  period  toward  the  relief  of 
man's  estate.  Still  we  must  not  forget  that  there  are  immense  labors 
yet  to  be  accomplished.  We  are  yet  surrounded  by  innumerable  mys- 
teries, which  can  only  be  solved  by  persistent  research.  Not  all  men  are 
fitted  by  temperament  or  training  to  engage  in  this  great  work,  but  more 
are  thus  fitted,  I  am  sure,  than  are  awakened  to  its  opportunities.  For 
those  of  you  who  are  ready,  here  is  a  challenge  to  the  supreme  use  of  all 
your  powers — to  your  imagination,  your  ingenuity,  your  patience  and 
enthusiasm,  and  to  your  spirit  of  disinterested  service. 


EXPERIENCES    OF   A   MEDICAL   TEACHERS 

By  W.  T.  Councilman,  M.D.,  LL.D., 
Professor  of  Pathology,  Harvard  University 

When  you  bestowed  upon  me  the  honor  of  an  invitation  to  address 
you  to-day,  it  was  probably  because  you  thought  that  in  the  course  of  a 
life,  more  than  thirty  years  of  which  have  been  devoted  to  study  and 
teaching  in  medicine,  I  should  have  formed  certain  conceptions  of  study 
and  teaching  which  were  based  on  a  long  experience  and  which  might 
have  some  value  to  the  young  men  before  me  who  are  in  the  beginning 
of  their  medical  career.  Some  of  these  conceptions  I  shall  endeavor 
to  impart,  but  of  their  value  I  can  not  judge.  Experience  is,  after  all, 
a  long  process  of  observation;  concepts  are  formed  early  and  constantly 
undergo  correction  as  the  field  enlarges  and  deepens;  they  are  of 
undoubted  value  for  the  individual  who  forms  them,  but  of  much  less 
value  to  those  to  whom  they  are  told.  Experience  can  not  be  trans- 
mitted, and  another  with  the  same  field  of  observation  may  form  other 
and  more  correct  concepts. 

I  shall  take  up  to-day  for  chief  consideration  that  part  of  my  life 
which  has  been  devoted  to  teaching,  and  the  subject  naturally  breaks 
up  into  several  parts  all  closely  connected.  The  first  concerns  the 
material  on  which  our  efforts  are  expended,  the  character  of  the  soil 
which  we  seek  to  till.  Let  us  first  endeavor  to  form  some  judgment  of 
the  effect  of  the  tillage  of  the  soil  previous  to  the  time  when  we  in  the 
medical  schools  take  up  our  tasks.  In  these  past  years  I  have  had 
under  my  hands  a  large  number  of  young  men  at  an  average  age  of 
twenty-three.  During  a  considerable  part  of  the  time  they  were  divided 
into  those  who  had  passed  through  college  and  had  acquired  an  A.B» 
degree  and  those  who  entered  the  school  after  fulfilling  certain  more 
or  less  indefinite  entrance  requirements.  Harvard  having  required 
the  A.B.  degree  as  a  condition  for  entrance  into  the  medical  school 
since  1900,  my  experience  has  been  more  extensive  with  students  with 
the  degree  than  with  those  without  it.      On  the  whole,  the  A.B.  men 

^Address  delivered  at  Syracuse  University,  June  11,  1912.  Published  in  the 
Boston  Medical  and  Surgical  Journal,  Vol.  CLXVI.,  June  27,  1912. 

21  305 


306  MEDICAL   BESEAECH   AND   EDUCATION 

are  better  than  the  men  without  the  degree.  In  Judging  of  the  effect 
of  the  college  training,  one  can  not  say  offhand  that  the  better  material 
which  comes  from  the  college  is  entirely  due  to  the  training  received 
there.  The  college  has  a  certain  advantage  in  that  its  material  repre- 
sents a  selection.  It  embraces  the  congenital  rich;  others,  whose 
immediate  forebears  by  energy  and  thrift  have  accumulated  means  suffi- 
cient to  give  their  sons  a  college  course;  and  a  large  number  of  young 
men  who  go  through  college  depending  upon  their  own  efforts  for  the 
means.  There  are  differences  in  the  environments  of  the  three  classes, 
so  many  advantages  and  disadvantages  connected  with  each,  that  I  am 
not  sure  whether  it  is  better  for  a  young  man  to  select  his  great-grand- 
father to  meet  his  college  expenses,  or  place  the  burden  upon  the  thrifty 
father  or  depend  upon  his  own  efforts.  From  all  these  classes  come 
men  who  on  the  whole  are  rather  better  than  the  men  who  have  not  had 
sufficient  means,  or,  in  the  lack  of  this,  sufficient  will  and  energy  to  put 
themselves  through  college. 

As  I  look  back  upon  my  life,  and  the  friendships  I  have  formed 
through  it,  many  of  my  friends  having  been  successful,  I  find  that  a 
large  proportion  of  them  have  not  had  the  college  degree.  It  must  be 
remembered,  however,  that  the  attainment  of  the  college  degree  is 
becoming  progressively  more  easy  and  that  most  of  these  men  at  the 
present  would  have  gone  through  college. 

With  the  view  of  estimating  in  actual  percentage  the  advantages 
of  the  college  degree,  I  made  for  a  number  of  years  a  comparison  of 
the  standing  of  the  men  in  my  course  who  had  or  had  not  the  degree. 
This  was  previous  to  the  year  1900  when  the  degree  was  demanded  for 
entrance.  The  men  were  rated  by  the  result  of  the  written  and  prac- 
tical examination  at  the  end  of  the  course,  by  the  character  of  their 
laboratory  work,  as  could  be  deduced  from  daily  observation,  and  by 
means  of  the  weekly  recitations.  Comparison  of  different  years  came 
out  very  evenly,  and  the  general  result  showed  a  difference  of  between 
four  and  five  per  cent,  in  favor  of  the  college  degree.  There  was  little 
difference  in  the  best  men  whether  they  had  or  had  not  the  degree,  but 
the  average  was  cut  down  by  the  very  poor  men  who  were  most  numer- 
ous in  the  class  without  the  degree.  Of  course,  such  an  inquiry  gives 
very  crude  results  which  are  of  little  value.  To  be  of  any  value,  the 
inquiry  should  extend  over  a  much  longer  period.  A  college  training 
should  give  much  more  than  an  ability  to  accomplish  certain  tasks  more 


EXPEEIENCES    OF    A    MEDICAL    TEACHER  307 

easily.  This  may  be  accomplished  by  acquiring  methods  of  study  and 
power  of  concentration,  both  of  which  come  with  practise. 

In  the  course  of  a  further  and  more  extensive  inquiry,  I  divided 
the  men  with  regard  to  the  character  of  their  studies  in  college,  taking 
also  the  character  of  their  college  into  consideration.  The  inquiry 
extended  over  a  sufficient  number  of  years  and  embraced  sufficient  indi- 
viduals to  make  the  results  of  some  value.  From  this  inquiry  it  was 
evident  that  the  men  who  had  devoted  a  considerable  part  of  their  time 
while  in  college  to  the  study  of  science  averaged  distinctly  higher  than 
the  men  whose  studies  were  along  more  classical  lines.  The  character 
of  the  scientific  studies  made  no  difference,  the  most  important  thing 
being  the  training  in  observation  and  judgment  which  such  studies 
gave.  Little  resulted  from  a  comparison  of  the  colleges ;  the  small  and 
the  large  colleges  seemed  to  be  about  on  a  par,  but  I  have  often  been 
able  to  see  in  some  of  the  best  students  the  effect  of  the  teaching  of 
some  particular  professor.  One  thing  came  out  regarding  the  colleges 
which  was  of  distinct  interest,  namely,  that  the  students  from  strictly 
ecclesiastical  colleges  had  lower  grades  as  compared  with  the  others  and 
their  average  was  even  less  than  that  of  men  without  a  degree.  It  is 
difficult  to  avoid  the  conclusion  that  a  certain  variety  of  collegiate 
training  may  be  a  detriment  rather  than  an  advantage.  Saints  do  not 
seem  very  well  to  look  after  the  colleges  which  bear  their  names,  or  they 
may  possibly  resent  such  colleges  being  used  to  provide  secular  educa- 
tion. It  is  also  true  that  we  should  not  blame  the  saint,  for  with  few 
exceptions  what  can  be  gleaned  from  history  would  lead  us  to  infer  that 
saints  have  at  best  but  a  very  imperfect  idea  of  education.  I  have 
amused  myself  by  extending  this  statistical  inquiry  in  other  ways,  one 
result  being  to  show  that  the  men  with  names  in  the  first  half  of  the 
alphabet  are  slightly  better  than  those  in  the  last  half,  but  possibly  in 
this  inquiry  I  may  have  had  a  personal  bias.  I  have  also  been  much 
interested  in  the  individuality  of  classes.  Classes  as  a  whole  are  always 
different;  as  one  looks  at  them  in  the  lecture  the  composite  expression 
differs,  the  laboratory  work  differs  and  the  relations  which  one  forms 
with  the  class  as  a  whole  differ  in  different  years.  I  think  that  this  is 
due  to  the  effect  of  a  few  men  in  the  different  classes  who  give  the  class 
its  tone. 

I  have  been  impressed  with  the  evidence  which  college  men  often 
present  of  a  lack  of  thoroughness  in  the  instruction  they  have  received. 


308  MEDICAL   BESEAECR   AND   EDUCATION 

This  lack  of  thoroughness  is  not  so  evident  in  those  who  have  had  some 
training  in  science.  Not  only  are  they  incapable  of  close  and  accurate 
observation,  but  they  show  a  singular  lack  of  facility  of  description. 
This  comes  out  strongly  in  some  of  the  exercises  of  the  course  in  which 
the  men  are  required  to  study  under  the  microscope  preparations  of 
diseased  tissue  with  which  they  are  not  familiar,  and  to  give  simple 
written  descriptions  of  the  conditions  present.  I  must  maintain  that 
educational  methods  are  extremely  imperfect  if  a  New  England  boy  at 
the  age  of  twenty-three  has  so  little  power  of  observation,  combined  with 
such  deficiency  of  curiosity,  that  he  can  not  recognize  an  American 
elm  at  sight,  and  this  is  often  the  case.  I  often  use  a  tree  which  stands 
across  the  street  from  the  laboratory  as  a  test  of  educational  methods. 
The  lack  of  thorouglmess  in  collegiate  training  is  apparent  also  in 
regard  to  languages.  Men  who  have  devoted  two  or  more  years  to  the 
study  of  French  or  German  have  acquired  no  facility  in  the  use  of  these 
languages.  From  my  acquaintance  with  German  students  and  with 
German  universities,  I  have  been  able  to  make  some  comparisons  be- 
tween their  methods  of  education  and  ours,  and  there  seems  to  be  much 
in  favor  of  the  German  methods.  Their  method  is  undoubtedly  much 
more  thorough  than  is  ours.  Much  more  is  demanded  of  the  student 
of  a  corresponding  age  not  only  in  the  scope  of  work,  but  in  the  thor- 
oughness of  accomplishment.  During  the  past  year,  while  visiting  a 
friend  in  Germany,  I  had  the  opportunity  of  seeing  something  of  the 
German  method  at  close  range.  The  son,  a  boy  of  fifteen  years,  who 
was  shortly  to  enter  the  gymnasium,  spent  in  school  thirty-four  hours 
weekly,  this  including  two  hours  of  field  work  and  two  hours  of  religious 
instruction.  In  addition  to  this,  he  worked  two  hours  daily  in  the 
evening.  In  the  gymnasium  the  drill  is  fully  as  strenuous,  and  when 
the  boy  leaves  this  to  enter  the  university  he  is  two  and  a  half  years 
ahead  of  the  American  boy  of  a  corresponding  age,  and  his  education 
has  been  conducted  along  rigid  lines  and  is  thorough.  This  rigid  sys- 
tem of  early  education  is  a  part  of  the  rigidity  of  German  life  which 
has  affected  everything  but  the  university.  With  the  entrance  of  the 
student  into  the  university  everything  is  changed,  for  there  he  finds  the 
utmost  freedom  in  choice  of  subject,  of  method  and  of  teacher.  With 
us  the  conditions  are  reversed;  we  give  a  great  deal  of  freedom  in  our 
rather  loose  early  education  and  apply  the  rigidity  later,  for  in  our 
university  work,  certainly  in  medicine,  there  is  a  rigidity  of  curriculum 


EXPEEIENCES    OF    A    MEDICAL    TEACEEE  309 

which  is  unknown  in  Germany.  Whether  there  is  any  compensating  ad- 
vantage in  the  laxity  of  our  early  education,  in  the  preponderating 
influence  of  athletics  in  our  colleges  which  theoretically  have  an  im- 
portance in  teaching  cooperation  and  in  giving  that  training  in  mind 
and  body  which  enables  unforeseen  conditions  quickly  to  be  met,  seems  to 
me  uncertain.  We  give  up  to  the  advantages  of  our  system  two  and  a 
half  of  the  ten  most  valuable  years  of  life.  Theoretically,  the  German 
system  should  tend  to  lack  of  independence  of  view,  to  a  too  ready  ac- 
ceptance of  authority,  but  there  is  no  evidence  of  this  to  be  seen  in  Ger- 
man work.  The  German  readily  accepts  authority  outside  of  his  domain 
of  thought,  but  there  he  demands  absolute  freedom.  With  us  there  is  a 
general  but  lax  disregard  of  authority ;  our  students  will  submit  to  the 
exercise  of  utmost  authority  in  matters  in  which  there  should  be  the  ut- 
most freedom.  The  outside  control  which  has  been  occasionally  evident 
in  American  universities,  and  exercised  in  the  limitations  of  freedom  of 
teaching,  of  thought  and  expression,  would  be  submitted  to  in  a  German 
university  by  neither  the  student  nor  the  teaching  body. 

From  this  rambling  talk  it  must  be  evident  that  I  am  very  uncertain 
what  should  be  demanded  of  a  student  as  a  fitting  preparation  for  medi- 
cine. A  college  degi'ee  certainly  seems  to  give  advantages  which  are 
definite  enough  to  be  expressed  in  percentage,  but  there  must  be  uncer- 
tainty as  to  whether  the  increased  percentage  is  due  to  the  college  or  to 
the  better  general  average  of  the  men  who  seek  the  college.  It  is  of  ad- 
vantage that  the  student  should  have  had  training  in  some  science  which 
M'ould  enable  him  to  acquire  the  scientific  method.  I  have  also  found 
that  the  student  is  greatly  assisted  by  having  acquired  some  facility  in 
free-hand  drawing.  Drawing  is  after  all  but  a  mode  of  expression;  it 
helps  enormously  in  accuracy  of  observation,  and  by  a  drawing  the  stu- 
dent often  can  convey  his  conception  of  an  object  more  accurately  than 
by  writing.  With  the  rapidly  advancing  loss  of  a  deciplicrable  calig- 
raphy,  some  substitute  for  writing  must  be  found.  On  the  whole,  there 
is  no  doubt  that  the  entire  medical  curriculum  will  be  made  easier  for 
the  student  and  he  will  derive  more  profit  from  his  work  if  he  has  ac- 
quired proper  methods  of  work,  and  these  methods  can  be  learned  in  any 
science,  but  preferably  in  some  biological  science. 

The  next  matter  concerns  the  end  sought  in  the  medical  training. 
The  time  has  arrived  in  medicine  when  knowledge  can  be  substituted  for 
conjecture.    The  relief  of  disease  is  dependent  upon  a  knowledge  of  the 


310  MEDICAL   EESEAECR    AND    EDUCATION 

conditions  of  life  in  the  diseased  individual,  and  this  knowledge  can  be 
obtained  only  from  the  study  of  the  sick  individual.  We  use  in  this 
study  the  senses,  and  methods  and  instruments  which  extend  them. 
Only  those  of  us  who  have  participated  in  the  medical  life  of  the  past 
forty  years  realize  how  great  has  been  the  change  in  the  medical  point  of 
view,  brought  about  by  the  enormous  increase  of  knowledge  of  disease. 
Forty  years  ago  it  was  possible  for  the  student  to  acquire  a  fairly  com- 
prehensive knowledge  of  medicine.  The  essentials  in  anatomy,  in  physi- 
ology, in  patholog}'  and  in  clinical  medicine  could  be  learned,  the  clin- 
ical methods  were  simple,  and  there  was  not  the  present  dependence  upon 
them.  There  was  but  little  known  as  to  the  cause  of  disease,  and  the 
acute  infectious  diseases  which  are  now  so  well  known  were  in  the  same 
category  in  which  many  of  the  chronic  organic  diseases  are  at  present. 
Indeed,  at  that  time  typhoid  fever  was  not  as  well  understood  as  chronic 
renal  disease  is  now. 

It  is  possible  to  name  the  directions  in  which  knowledge  has  most  ad- 
vanced :  In  parasitology,  which  has  taught  us  the  causes  of  the  infectious 
diseases,  and  in  many  cases  what  is  more  important,  the  manner  of  in- 
fection and  the  mode  of  avoidance;  in  the  knowledge  of  the  subtle 
changes  in  the  blood  serum  which  underlie  immunity ;  in  the  knowledge 
of  the  function  of  the  ductless  glands  and  the  part  which  they  play  in 
health  and  disease;  in  the  great  increase  of  knowledge  of  the  anatomy 
and  pathology  of  the  nervous  system;  lastl}^,  the  more  thorough  knowl- 
edge of  the  chemical  processes  which  take  place  in  the  body.  There  has 
been  some  attempt  to  give  to  the  student  all  that  is  new  in  addition  to 
the  old.  The  teacher  in  any  department  of  medicine  is  confronted  with 
masses  of  facts  which  he  feels  that  the  student  must  acquire.  It  is  true 
that  the  period  of  medical  study  has  been  lengthened  and  the  lengthen- 
ing has  not  been  completed,  but  the  attempt  to  place  the  student  in  the 
same  relation  to  medical  knowledge  which  was  possible  forty  years  ago 
is  fruitless.  The  object  to  be  attained  in  medical  education  is  a  training 
which  will  enable  its  recipient  to  be  of  service  to  the  people  in  relation  to 
disease.  There  are  certain  fundamental  facts  which  have  in  medical 
education  the  same  relation  as  have  the  three  E's  in  the  child's  training, 
and  these  must  be  possessed  of,  but  further  than  this  the  student  must 
have  the  training  and  the  methods  of  acquiring  knowledge.  Disease,  as 
the  practitioner  comes  in  contact  with  it,  affects  not  classes,  but  individ- 
uals, and  the  individual  case  of  disease  will  always  be  for  him  a  problem 


EXPEEIENCES    OF    A    MEDICAL    TEACH EE  311 

to  be  investigated.  The  mere  matter  of  diagnosis  as  far  as  naming  the 
pathological  process  and  ascertaining  its  situation  is  concerned  may  be 
regarded  as  comparatively  easy,  although  every  pathologist  is  aware  of 
the  number  and  importance  of  the  mistakes  which  are  made  in  this.  As 
a  result  of  disease,  certain  conditions  which  bring  about  functional  dis- 
turbance are  produced  and  life  goes  on  under  conditions  which  dijEfer 
from  the  normal.  One  of  the  distinguishing  criteria  of  living  matter  is 
its  variability,  of  which  individuality  is  the  expression,  and  in  conse- 
quence of  this  the  result  of  the  abnormal  environment  of  disease  must 
differ  in  every  individual.  The  knowledge  of  disease  in  the  individual, 
on  which  rational  procedures  of  relief  are  based,  can  not  come  from  pre- 
vious experience  nor  from  the  experience  of  others,  nor  from  generaliza- 
tions, but  must  be  educed  from  the  investigation  of  the  individual  case, 
and  in  such  investigations  methods  which  aid  the  senses  are  of  para- 
mount importance.  The  student  must  have  become  familiar  with 
methods  by  constant  exercise  in  them,  and  he  must  have  learned  through 
the  work  of  his  teachers  respect  for  and  dependence  upon  knowledge. 
The  full  recognition  of  the  individuality  of  disease,  carrying  with  it  the 
necessity  of  detailed  investigation  of  every  case,  is  the  most  important 
general  conception  of  disease  which  has  been  arrived  at.  Diseases  with 
the  appropriate  remedies  can  not  be  tagged  and  placed  in  pigeon-holes. 
It  is  possible  to  think  of  conditions  in  the  individual  which  might 
modify  the  use  of  such  therapeutic  measures  as  we  have  even  in  malaria, 
diphtheria  and  syphilis.  Can  we  so  educate  our  men  that  we  can  turn 
out,  on  the  one  hand,  good  practitioners,  and,  on  the  other,  men  who  are 
investigators,  teachers  and  skilled  in  research  ?  I  deny  both  the  possibil- 
ity and  the  desirability  of  such  a  distinction.  It  is  wearying  to  hear  re- 
search spoken  of  as  though  it  were  a  special  calling  demanding  special 
methods,  a  special  order  of  mind  and  a  special  environment  for  its  prose- 
cution. In  medicine  research  is  but  the  investigation  by  the  methods  of 
science  of  the  problems  presented  by  disease,  and  the  practitioner  in  his 
daily  calling  is  as  truly  engaged  in  research  as  the  laboratory  and  hos- 
pital worker,  even  though  he  may  not  feel  it  incumbent  to  publish  his 
results.  The  whole  result  of  medical  education  should  be  to  enable  the 
graduate  to  continue  to  seek  knowledge  by  scientific  methods. 

The  practitioner  will  need  other  than  medical  knowledge,  but  it  is 
doubtful  if  any  process  of  education  will  give  it  to  him.  He  must  con- 
sider not  only  the  sick  individual,  but  the  family,  and  the  entire  environ- 


312  MEDICAL   BESEAECH   AND    EDUCATION 

ment,  and  in  this  regard  his  services  may  be  of  greater  importance  than 
to  the  case.  Disease  is  an  important  element  in  sociology,  and  certain 
diseases  such  as  tuberculosis  are  probably  more  closely  related  to  social 
conditions  and  as  a  class  are  rather  to  be  met  by  social  than  medical 
measures.  It  is  impossible  for  the  medical  man  to  cope  fully  with  the 
duties  he  has  assumed  unless  in  addition  to  his  medical  training  he  has 
knowledge  of  the  nature  of  man  and  the  wide  sympathy  which  such 
knowledge  should  bring.  As  I  have  been  writing  the  last  few  pages,  I 
have  endeavored  to  recall  to  my  mind  the  great  physicians  whom  I  have 
known,  some  through  their  work,  others  personally.  Some  have  been 
teachers  and  writers  who  have  exerted  a  wide  influence,  some  have  been 
active  practitioners  in  a  narrow  environment  beyond  which  their  name 
and  fame  have  not  extended.  But  there  is  this  in  common :  they  were  all 
of  them  investigators;  they  sought  definite  knowledge  of  disease  as  a 
basis  for  treatment;  and  they  are  all  men  of  wide  human  sympathies. 

After  this  dissertation  on  the  object  of  medical  study,  which  seems  to 
me  as  vague  as  the  part  relating  to  the  student,  I  must  come  to  the  third 
part, — that  relating  to  the  methods  of  teaching,  which  I  fear  will  also  be 
cloudy.  Provided  certain  things  are  held  prominently  in  view,  there  can 
be  wide  variation  in  methods.  No  two  schools  can  be  alike,  since  each  is 
founded  upon  the  individuality  of  the  teaching  i)ody  and  the  facilities 
for  teaching  which  it  possesses.  There  will  be  certain  men  of  surpassing 
influence  in  one  school  and  in  one  department,  and  in  other  schools  some 
other  department  will  be  equally  strong.  It  is  not  in  the  interests  of 
medical  education  that  all  schools  should  be  poured  into  the  same  mold. 

I  am  still  one  of  those  who  believe  that  teaching  is  a  calling  which, 
if  engaged  in,  should  be  the  paramount  interest  in  life, — that  it  is  a  re- 
sponsible, serious  and  noble  calling.  I  regret  the  tendency  which  seems 
to  prevail  of  rather  disregarding  teaching  as  a  career.  I  have  become 
aware  of  this  in  several  ways.  From  my  laboratory  large  numbers  of 
young  men  after  serving  as  assistants  for  a  couple  of  years  have  taken 
positions  elsewhere.  In  the  inquiries  from  other  institutions  for  men, 
the  ability  to  teach  is  seldom  inquired  into,  or  at  least  little  stress  is  laid 
upon  it  in  the  list  of  accomplishments  demanded  for  small  pay.  The 
young  men  themselves  in  seeking  positions  make  very  definite  demands 
as  to  the  hours  which  are  to  be  devoted  to  teaching.  Their  ideal  seems 
to  be  a  life  devoted  to  research, — a  perfectly  proper  ideal,  but  why  not 
research  with  and  through  teaching  ?    Teaching  should  not  interrupt  re- 


EXPEEIENCES    OF    A    MEDICAL    TEACHER  313 

search,  for  student  and  teacher  should  seek  knowledge  together,  and  even 
teaching  involves  so  much  of  the  unknown  that  to  engage  conscientiously 
in  it  is  a  form  of  research.  There  is  too  much  tendency  to  regard  re- 
search and  publication  as  sjmonymous.  It  is  a  laudable  ambition  to  be 
known  as  a  contributor  to  medical  knowledge,  and  while  teaching  may 
impede  publication,  it  is,  if  properly  pursued,  a  stimulus  to  research. 
There  are  rewards  which  come  to  the  teacher  alone.  Who  can  not  re- 
member certain  teachers  who  have  exerted  an  influence  lasting  through 
life,  and  these,  as  models,  are  always  before  us. 

Since  medical  education  consists  essentially  in  training  in  methods, 
study  in  the  laboratory  and  hospital  wards  have  largely  superseded  the 
old  methods  in  which  the  lecture  and  note-book  played  the  prominent 
part.  I  say  the  lecture  and  the  note-book,  meaning  the  association  of 
the  two,  for  the  note-book  in  which  the  student  records  his  observations 
is  still  an  important  instrument  of  education.  In  the  past  years  there 
has  been  an  enormous  extension  of  study  in  the  laboratory.  Much  of 
the  increased  length  of  the  curriculum  has  been  used  up  by  an  increase 
of  the  time  given  to  laboratory  study  in  the  so-called  medical  sciences. 
It  is  not  impossible  that  too  much  time  is  given  to  these  subjects.  In 
the  old  schools,  for  instance,  anatomy  was  more  essential  than  it  is  to- 
day, for  it  was  in  the  dissecting  room  only  that  the  student  studied  the 
material  and  received  some  training  in  scientific  methods.  In  physiol- 
ogy the  student  in  addition  to  the  lectures  and  demonstrations  carries 
out  certain  experiments  himself,  and  the  same  methods  of  study  are 
used  in  pathology  and  practically  in  all  the  departments.  With  regard 
to  the  importance  of  the  lecture,  opinions  vary  widely.  I  have  always 
used  the  lecture  method  to  a  considerable  extent,  and  I  think  it  is  of 
value  provided  we  have  a  clear  idea  of  what  the  lecture  should  aim  to 
accomplish.  However  good  may  be  the  descriptive  power  of  the  lec- 
turer, however  able  he  may  be  in  interesting  his  audience,  it  is  useless 
to  attempt  to  give  in  a  lecture  information  on  a  complex  subject.  For 
instance,  I  doubt  if  it  would  be  possible  for  a  lecturer,  taking  a  group  of 
men  of  the  average  intelligence,  but  coming  from  a  world  in  which 
there  were  no  tre?s,  to  enable  them  in  an  hour  to  form  such  a  concep- 
tion of  an  oak  or  elm  that  they  could  go  out  from  the  lecture  and  in- 
stantly recognize  such  a  tree.  I  have  arrived  at  this  view  from  personal 
experience  which  may  not  be  complimentary.  I  have  endeavored  to  as- 
certain from  students  before  whom  I  had  lectured  on  a  topic  in  which  I 


314  MEDICAL   BESEABCH   AND   EDUCATION 

was  certainly  interested,  and  they  seemed  to  be,  how  much  correct  in- 
formation they  had  acquired,  and  have  found  it  surprisingly  small  in 
amount.  I  think  that  the  lecture  has  a  distinct  place  in  expanding  and 
correlating  knowledge  which  the  student  has  already  acquired.  It 
should  also  convey  a  stimulus  to  the  student,  and  the  lecture  hour  should 
form  an  agreeable  interruption  of  the  laboratory  work.  Unless  the  stu- 
dent can  gain  in  the  lecture  mental  recreation  and  stimulation,  the  lec- 
ture had  better  be  left  out  were  it  not  for  the  aspects  which  are  not 
usually  regarded  as  among  its  assets.  One  is  its  power  of  inducing 
gentle,  refreshing,  noiseless  sleep  in.  the  audience,  and  the  other  is  the 
educational  value  of  the  lecture  to  the  lecturer.  To  one  who  is  a  poor 
sleeper  there  comes  a  great  satisfaction  to  see  sleep  descend  upon  an 
audience.  The  lecturer  experiences  an  exhilaration  at  the  demonstration 
of  the  possession  of  a  power  which  makes  him  akin  to  the  God  "who 
giveth  his  beloved  sleep."  I  lay  stress  upon  the  condition  that  the  sleep 
shall  be  noiseless,  and  position  makes  lecture  room  sleep  usually  of  this 
character.  I  remember  once  on  an  occasion  such  as  this  of  being  really 
disturbed  at  the  noiseful  apoplectic  sleep  of  the  worthy  man  who  had  in- 
voked the  deity.  With  regard  to  the  second  point,  how  often  the  crudity 
of  an  idea  becomes  strongly  apparent  when  the  attempt  is  made  in  the 
lecture  to  convey  the  idea  to  others.  How  often  have  I  seen  a  cul  de  sac 
rise  before  me  into  which  I  was  on  the  verge  of  a  headlong  plunge ! 
How  eagerly  is  a  friendly  alley  availed  of  as  a  means  of  escape!  The 
teacher  should  find  in  the  lecture  a  means  of  clarifying  his  knowledge, 
and  in  the  stimulus  of  lecturing  very  often  new  and  useful  points  of 
view  present  themselves. 

Next  to  the  lecturer  in  ascending  value  comes  the  demonstration, 
also  a  method  of  value,  but  of  over-rated  value.  It  is  possible  to  gather 
a  few  men,  not  more  than  ten,  around  certain  objects,  point  out  the  es- 
sential things,  and  enable  them  to  see  them  as  does  the  demonstrator. 
Such  a  demonstration  can  also  be  made  the  basis  of  an  informal  talk, 
and  questions  can  be  asked,  but  at  the  best  it  is  little  more  than  a  pro- 
jection of  the  ideas  of  the  demonstrator. 

The  real  work  of  the  student  is  in  the  laboratory,  for  this,  as  its 
name  implies,  is  the  workshop.  In  this  he  should  find  apparatus  and 
material  for  study  and  an  arrangement  of  light  and  space  which  facili- 
tates study.  Light  and  ventilation  should  be  carefully  provided,  for 
they  affect  greatly  the  character  of  the  work.    One  hears  something  said 


EXPERIENCES    OF    A    MEDICAL    TEACHER  315 

about  the  advantages  of  the  laboratory  as  providing  elbow  instruction 
for  the  students.  In  my  opinion,  elbow  instruction  is  to  be  avoided.  In 
the  laboratory,  the  student  has  the  material  for  study,  his  study  can  be 
supervised  and  directed,  but  the  knowledge  he  obtains  must  be  first-hand 
knowledge  and  come  to  him  from  the  material.  I  hold  that  it  is  better 
for  a  student  to  work  for  an  hour  over  the  solution  of  a  question  which 
presents  in  his  work  than  to  have  an  explanation  which  may  possibly  be 
given  in  a  minute.  In  connection  with  his  laboratory  work  the  student 
should  be  encouraged  to  read.  Text-books  should  be  accessible  in  the 
laboratory,  and  a  well-chosen  library  near  at  hand.  He  should  be  re- 
ferred to  classical  original  articles  on  the  subjects  of  study.  There  is  a 
wonderful  freshness  in  an  important  original  communication,  and  a 
stimulus  is  conveyed  through  the  written  page.  Students  differ  greatly 
in  the  profit  and  pleasure  which  comes  from  reading  of  this  sort.  They 
are  too  apt  to  think  that  their  work  consists  in  acquiring  facts.  Facts 
there  are,  and  they  must  be  acquired,  but  the  process  of  acquiring  is  very 
indirect,  and  the  most  important  facts  are  always  those  in  the  distance. 
I  have  often  thought  it  might  be  of  advantage  to  substitute  the  reading 
of  original  work  for  the  lecture.  In  the  selection  of  reading  for  the  stu- 
dents it  is  interesting  to  find  how  generally  one  chooses  the  early  work 
of  an  author,  something  \\Titten  under  the  spell  of  youth.  There  is  a 
freshness,  a  directness  of  expression  in  early  work  which  is  not  so  evi- 
dent in  the  later.  In  the  beginning  of  laboratory  work  the  students  may 
require  considerable  help  and  supervision,  but  after  a  few  weeks  this  is 
no  longer  so.  I  have  found  it  convenient  to  divide  the  large  class  in  the 
laboratory  into  smaller  units  of  ten  students.  The  demonstrations  are 
given  to  these  units,  and  they  go  to  the  hospitals  to  attend  and  assist  in 
the  autopsies.  To  a  certain  extent  each  unit  works  independently,  for 
each  brings  from  the  autopsy  material  for  further  study.  In  this  way 
the  men  help  each  other  in  their  work,  and  each  profits  to  a  certain  ex- 
tent from  the  work  of  his  fellows.  I  have  not  favored  recitations  from 
text-books,  and  have  substituted  for  this  an  exercise  which  is  held 
weekly,  and  consists  in  the  study  and  description  of  microscopical  speci- 
mens which  are  unknown.  The  papers  are  criticized,  marked  and  re- 
turned. This  constant  criticism  enables  the  student  to  place  himself ;  he 
sees  whether  or  not  he  is  progressing,  and  in  what  direction  he  should 
improve. 

I  have  always  used  the  experimental  method  to  some  extent,  and  dur- 


316  MEDICAL   BESEABCH   AND    EDUCATION 

ing  the  last  year  to  a  much  greater  extent  than  before,  and  with  advan- 
tage. Each  unit  carries  out  in  turn,  and  under  supervision,  certain  ex- 
periments on  anesthetized  animals.  The  experiments  mainly  relate  to 
inflammation,  to  the  circulation,  to  the  infections,  -and  include  certain 
experimentally  produced  organic  lesions.  Each  experiment  is  closely 
related  to  the  subject  which  is  being  studied  at  the  time,  and  the  results 
are  demonstrated  to  the  entire  class  by  those  conducting  them.  The  ex- 
periment clarifies,  from  the  complex  factors  of  disease  single  ones  can 
be  selected  and  their  effect  studied.  How  much  simpler  to  show  on  an 
anesthetized  animal  what  happens  in  increased  pericardial  pressure;  to 
show  the  variations  in  an  infection  depending  upon  the  route ;  to  show 
the  structural  with  the  functional  effects  of  an  organic  disease ;  to  show 
the  stages  in  the  production  of  a  lesion,  than,  without  the  experiment  to 
describe,  to  demonstrate  or  to  study  the  mere  products  of  disease.  Such 
experimental  work  demands  space  and  facilities.  It  must  be  carried  out 
with  dignity  and  with  the  high  conscientious  regard  for  animal  suffer- 
ing which  will  compel  its  avoidance.  Students  can  also  be  encouraged 
to  carry  out  on  each  other  certain  harmless,  interesting  and  instructive 
experiments  on  the  circulation. 

In  speaking  of  teaching,  I  have  of  necessity  thought  more  of  my  own 
subject,  but  I  do  not  believe  that  there  is  any  real  difference  in  the 
method  to  be  pursued  in  teaching  any  branch  of  medicine,  or,  indeed, 
any  branch  of  science.  It  seems,  however,  so  much  easier  to  give  the  stu- 
dent facts,  or  rather  those  concepts  which  we  form  and  in  our  vanity 
regard  as  facts,  and  to  fill  up  the  vacant  places  of  his  mind  with  our 
knowledge  as  a  bucket  is  filled  with  water,  but  such  a  process  is  not  edu- 
cation. 

And  now  a  few  words  especially  directed  to  the  young  men  before 
me.  You  have  not  completed  your  studies,  you  have  acquired  some 
knowledge  and,  more  important,  you  have  acquired  methods  which  will 
enable  you  to  go  further.  The  reputation  of  your  school,  the  facilities 
for  study  which  it  affords  and  the  character  of  your  teachers  are  a  guar- 
antee that  you  have  had  the  opportunities.  You  are  about  to  enter  upon 
a  life  which  will  bring  you  into  intimate  relations  with  all  the  aspects  of 
the  complex  conditions  of  disease.  You  will  come  in  contact  with  hu- 
manity in  its  best  and  its  worst  aspects,  for  disease  strips  off  the  con- 
ventional outer  covering,  and  the  moral  nature  is  laid  bare.  You  will 
see  depths  of  selfislmess  and,  on  the  other  hand,  supreme  sacrifice  of  self 


EXPEEIENCES    OF    A    MEDICAL    TEACHER  317 

for  others,  such  as  no  other  calling  will  reveal  to  you.  You  are  entering 
upon  the  most  altruistic  of  professions,  one  in  which  the  best  efforts  of 
its  members  are  directed  toward  the  physical  and  moral  betterment  of 
the  race.  If  philanthropy  be  evinced  in  deeds  of  practical  beneficence 
towards  the  race,  then  Jenner,  Pasteur,  Koch,  Eeed,  to  mention  a  few 
names  only,  have  been  the  gi-eatest  of  all  philanthropists.  This  form  of 
philanthropy  is  open  to  you,  there  are  numbers  of  questions  awaiting 
solution  by  you,  and  the  knowledge  which  you  may  give  the  world  may 
be  of  inestimable  benefit.  The  world  knows  as  the  philanthropist  only 
him  who  gives  money  out  of  his  superabundance,  which  is,  after  all,  a 
most  uncertain  way  of  conferring  benefit,  but  the  only  one  which  is 
open  to  many,  and  which  most  of  us  think  is  not  availed  of  to  a  suflB- 
cient  degree.  However,  you  need  not  concern  yourself  about  this  form 
of  philanthropy,  for  it  is  almost  impossible  that  it  should  come  in  your 
way  to  exercise  it.  You  must  make  up  your  mind  in  the  beginning  that 
your  life  is  going  to  be  arduous,  that  there  are  few  prizes,  that  the  road 
to  even  that  degree  of  financial  success  which  will  enable  you  to  estab- 
lish a  home  and  family  in  comfort  is  now  and  is  becoming  increasingly 
difficult.  One  of  the  reasons  for  this  is  that  disease  as  it  affects  the 
masses  is  being  recognized  as  the  chief  of  the  social  problems.  This  rec- 
ognition is  seen  in  the  growing  provision  of  hospitals  and  dispensaries, 
in  the  pure-food  laws,  in  the  wider  extension  and  increased  efficiency  of 
the  work  of  boards  of  health.  Such  work  will  not  diminish,  but  will  in- 
crease. Tuberculosis  is  being  more  and  more  removed  from  exclusive 
medical  care,  and  the  success  which  has  attended  the  modern  methods  of 
caring  for  it  will  be  extended  to  other  diseases.  The  medical  inspection 
of  schools  and  factories  are  social  measures  and  diminish  the  impor- 
tance of  your  efforts,  which  concern  chiefly  disease  in  the  individual. 
This  is  an  age  in  which  increased  efficiency  of  effort  is  being  sought  in 
every  direction,  and  there  is  a  great  loss  of  effort  in  the  practise  of  medi- 
cine. In  spite  of  all  this,  one  of  your  duties  will  be  to  so  educate  the 
public  with  which  you  come  in  contact,  in  knowledge  of  disease  and  of 
factors  causing  it,  that  social  measures  can  be  made  more  effective.  As 
an  offset  to  the  fewer  individual  patients  which  the  future  will  bring, 
there  will  be  increased  demand  for  physicians  employed  in  a  public  ca- 
pacity, an  increasing  number  of  medical  positions  in  institutions  of 
various  sorts  will  have  to  be  filled. 

In  your  outlook  on  life  be  optimistic.    There  may  be  some  germ  of 


318  MEDICAL   BESEABCH   AND   EDUCATION 

truth  in  the  idea  that  optimists,  like  poets,  are  born  and  not  made,  but 
optimism  is  more  easily  attained  than  is  the  poetic  faculty.  A  man  is 
an  optimist  or  a  pessimist  according  to  his  vision,  for,  contrary  to  the 
adage  which  implies  a  distrust  in  vision,  "Things  are  always  as  they 
seem."  If  you  do  not  possess  optimism,  acquire  it,  for  there  can  be 
moral  as  well  as  religious  conversion.  There  is  much  good  in  the  world, 
rather  more  than  evil,  but  possibly  not  so  obvious  without  vision  trained 
to  recognize  the  good.  You  can  go  through  life  with  the  environment 
of  a  stony  desert,  or  you  can  walk  through  green  fields,  and  hear  bab- 
bling brooks  and  the  songs  of  birds  and  the  voices  of  children  at  play, 
and  rest  in  the  shade  of  mighty  trees  by  the  banks  of  rivers,  all  depend- 
ing on  whether  you  see  good  or  evil.^  Do  not  be  afraid  of  the  future ; 
trust  your  own  powers.  It  is  a  great  thing  to  know,  and  you  may  ac- 
cept it,  for  it  is  true,  that  success  comes  to  the  individual  who  under  all 
circumstances  does  his  best;  and  one  will  always  do  his  best  in  that 
work  which  gives  him  the  most  joy  in  the  doing.  There  is  no  criterion 
for  success  and  reward,  for  both  depend  upon  the  point  of  view.  There 
is  an  abundance  of  work  to  do,  and  room  in  the  world  and  food  and 
water  and  raiment  for  the  honest  worker,  and  the  greatest  happiness 
lies  in  work. 

"  Little  do  ye  know  your  own  blessedness ;  for  to  travel  hopefully  is 
a  better  thing  than  to  arrive,  and  the  true  success  is  to  labour." — E.  L.  S., 
"  El  Dorado." 

'  On  critically  reading  this,  the  writer  feels  that  some  further  elucidation  is 
necessary.  Of  course,  it  is  possible  for  a  man  to  create  about  himself  a  fool's 
paradise  in  which  he  may  dwell  in  happy  contentment.  He  can  quickly  create 
such  an  environment  by  well-selected  stages  of  alcoholic  intoxication.  The  great 
trouble  comes  with  the  voluntary  selection  of  optimism  as  a  career.  To  most 
men,  evil  becomes  deterrent  by  its  exhibition  in  others.  Thus,  to  the  pure  in 
heart,  vice  by  demonstration  is  made  abhorrent;  to  earnest,  sober  men,  drunken- 
ness is  unattractive,  and  an  agent  at  times  so  useful  as  is  alcohol  may  be  totally 
condemned.  Although  some  may  temporarily  cover  themselves  with  a  cloak  of 
optimism,  using  it  as  the  wolf  used  the  sheep  skin,  the  only  genuine  and  constant 
optimists  are  the  beneficiaries  of  a  protective  tariff,  syphilitics  in  the  early  stages 
of  general  paralysis,  some  successful  clinicians,  who  turn  to  financial  use  their 
God-given  intuitions  of  disease,  and  some  presidents  of  colleges.  The  revelations 
of  optimism  which  one  gains  from  these  sources  make  the  state  of  mind  seem 
unattractive.  But  on  the  other  hand  if  the  world  as  seen  seems  good  don't 
change  your  glasses. 


/ 


MEDICAL  RESEARCH:  ITS  PLACE   IN  THE  UNIVERSITY 

MEDICAL    SCHOOL^ 

By  Theobald  Smith,  A.M.,  M.D. 

George  Fabyan  Professor  of  Comparative  Pathology  in  the 
Harvard  Medical  School 

If  there  be  one  word  wMch  is  heard  most  frequently  in  the  most 
intelligent  circles  interested  in  professional  education  to-day,  it  is  the 
word  research.  In  our  own  country  in  recent  years  medicine  has  fallen 
under  its  sway,  and  on  all  sides  efforts  are  being  made  to  meet  its 
demands  by  the  erection  and  equipment  of  costly  laboratories  within 
whose  walls  research  may  be  carried  on  in  a  continuous  and  orderly 
manner. 

Granted  that  the  governing  bodies  of  our  great  universities  have 
familiarized  themselves  with  the  significance  of  this  word  and  are 
giving  it  out,  some  only  with  the  lips,  others  with  a  thorough  conviction 
that  to  it  must  be  accorded  a  permanent  place  in  our  higher  institu- 
tions, the  problem  of  how  to  deal  with  such  a  costly,  and  in  many  ways 
unattractive,  offspring,  how  to  correlate  it  with  the  teaching  function, 
how  to  cultivate  it  side  by  side  with  the  routine  methods  of  instruction, 
will  occupy  a  prominent  place  for  years  to  come. 

Research  signifies  effort  directed  toward  the  discovery  of  laws  and 
principles  through  the  systematic  collection  of  new,  and  the  better 
correlation  of  existing,  data.  It  also  means  effort  directed  toward  the 
more  efficient  and  economical  application  of  discoveries  to  the  welfare 
of  man,  in  other  words,  the  utilization  of  latent  and  hitherto  wasted 
energy.  The  aims  of  research  are  not  culture,  not  miscellaneous  infor- 
mation, not  a  mood  of  leisure  meditation  upon  the  origin  of  things,  but 
mainly  utility  and  service  to  mankind. 

The  chief  influence  at  work  in  lifting  medicine  from  a  mere  teaching 
to  a  research  level  is  the  same  as  that  at  work  throughout  the  world  of 
science  and  in  fact  in  all  intellectual  fields.  If  we  examine  it  more 
closely  we  find  it  akin  to  the  breaking  away  from  authority  and  dog- 

*  Address  before  the  Harvard  Medical  Alumni  Association  of  New  York 
City,  November  26,  1904.    Published  in  the  Popular  Science  Monthly,  April,  1905. 

319 


320  MEDICAL   BESEABCH   AND   EDUCATION 

matism  in  religious  affairs  and  from  autocracy  in  the  government  of 
nations.  Its  foundations  rest  far  down  in  the  great  liberalizing  wave 
of  the  nineteenth  century.  We  no  longer  believe  that  each  step  in 
advance  is  the  ultimate  one^  but  only  one  in  a  series  toward  ultimate 
truth,  and  this  fact  makes  us  realize  that  we  must  keep  on  marching. 
Research  recognizes  no  immediate  boundary  to  its  activities,  and  no 
limit  to  its  possible  acquisitions.  In  placing  only  a  temporary  value 
upon  its  constructive  plans  and  using  theories  only  as  aids  to  new  facts, 
science  grows  in  candor  and  modesty  with  its  achievements. 

In  biology  and  medicine,  the  spirit  of  research  takes  into  account 
the  continual  movement  and  flux  in  living  things  and  their  environ- 
ment. It  is  a  study  of  change,  of  transformation,  brought  about  by 
conditions  which  may  or  may  not  be  under  experimental  control.  We 
describe  carefully  and  minutely,  not  for  the  sake  of  the  picture  and 
its  details,  but  chiefly  to  be  able  to  recognize  the  change.  Unless  we 
know  the  consecutive  pictures  how  can  we  detect  the  movement  and  its 
trend  ?  It  is  the  moving  picture  of  the  kinetoscope  that  has  gradually 
replaced  the  single  view  in  repose. 

But  there  is  danger  that  we  may  move  too  rapidly  and  find  our 
advanced  positions  untenable.  The  world  is  just  now  very  optimistic 
and  expectations  run  high.  If  we  give  way  "to  the  feverish  haste  of 
our  day,  the  slow,  sure  advance  of  medical  science  may  be  brought 
into  discredit.  For  it  is  one  of  the  features  of  this  feverish  haste  to 
leave  the  position  held  as  soon  as  possible  for  one  more  advanced.  We 
move  away  because  we  have  some  doubt  as  to  the  security  and  trust- 
worthiness of  our  present  position,  and  we  hope  to  gain  by  pushing 
beyond  it  rather  than  strengthening  it.  As  a  result  of  this  attitude 
we  find  the  thing  most  characteristic  of  the  day  and  age  is  the  rapid 
remolding  of  our  stock  of  information.  Eevolutionary  views  are  ut- 
tered from  an  inadequate  basis  of  observational  and  experimental  data. 
Theories  become  kaleidoscopic  in  their  variety.  Old  views  long  since 
discarded  come  to  the  surface  like  old  fashions.  All  this  change  and 
ferment  is  both  the  cause  and  the  effect  of  the  enquiring  attitude  of 
mind.  Research  begets  new  data  and  the  opposition  to  these  begets 
new  research.  Thus  the  fermentation  is  kept  up  and  a  froth  several 
years  deep  lies  on  the  surface  which  few  can  penetrate. 

This  haste  and  hurry  is  part  and  parcel  of  what  might  be  called 
nature's  lavish  waste  of  energy.      The  volume  of  our  information  in- 


MEDICAL   BESEAECH  321 

creases  more  rapidly  than  our  knowledge  of  the  principles  which  under- 
lie and  support  it.  The  progress  actually  made  is  more  apparent  than 
real.  It  is  a  swaying  to  and  fro  with  but  little  forward  movement. 
Like  the  driftwood  of  which  the  waves  are  endeavoring  to  unburden 
themselves,  many  excursions  back  and  forth  must  be  made  before  the 
fact  is  finally  landed.    It  is  often  much  battered  and  barely  recognizable. 

That  there  is  here  a  golden  mean  to  be  followed  need  not  be  em- 
phasized. The  spirit  of  research  should  be  properly  tempered  by  a 
true  insight  into  the  relation  of  enquiry  to  the  great  accumulation  of 
knowledge  and  the  reserve  forces  stored  in  the  every-day  experience 
of  mankind  and  handed  down  from  generation  to  generation. 

In  the  meantime  the  optimism  of  the  world  which  unknowingly 
assumes  that  medical  science  can  rise  above  natural  law  and  correct 
any  and  all  excesses  of  individuals  and  communities  must  be  met  by  a 
better  education  in  natural  science  rather  than  abandoned  to  the 
manipulations  of  the  charlatans  of  physical  and  mental  healing. 

Passing  now  to  the  more  obvious  external  conditions  which  have 
tended  to  stimulate  medical  research,  we  may  single  out  a  few  which 
have  been  of  special  importance.  Perhaps  the  most  ancient  and 
strongest  of  all  is  the  desire  in  the  human  breast  to  maintain  health 
and  prolong  life.  From  its  very  beginnings  the  healing  art  has  been 
weighed  down  with  the  greatest  of  problems,  to  save  life  and  to  cure 
disease,  often  in  those  of  lofty  estate,  and  its  status  for  the  time  being 
frequently  depended  on  its  success  or  failure  in  accomplishing  appar- 
ently the  impossible.  In  our  own  day  the  crumbling  of  the  formal 
religious  belief  that  this  life  is  but  a  preparation  for  that  beyond  the 
grave  and  the  centering  of  our  efforts  to  make  it  as  much  of  a  success 
as  possible,  the  growth  of  wealth  and  leisure  and  the  pursuit  of  sensual 
pleasure,  these  various  motives,  high  and  low,  combine  to  exert  a  pres- 
sure upon  medicine  which  is  scarcely  equaled  in  other  professions. 
To  save  life  and  to  cure  disease  are  imperative  demands  which  grow 
more  urgent,  more  impatient  each  year,  and  which  suffice  to  quicken 
the  efforts  of  the  scientist  and  the  true  physician  as  well  as  the  char- 
latan, and  shape  almost  every  problem  which  is  considered  worthy  of 
attack  to-day. 

As  a  most  important  and  timely  contributory  force  to  the  advance- 
ment of  medical  research  in  recent  years  are  the  princely  gifts  of  bene- 
factors, with  whom  we  especially  associate  the  names  of  Johns  Hopkins, 

22 


322  MEDICAL   EESEAECH   AND    EDUCATION 

Garrett,  Fabyan,  Eockefeller,  McCormack,  Payne,  Morgan,  Hunting- 
don, Sears,  Stillman,  and  many  others  without  whose  aid  medical 
research  could  hardly  have  commanded  a  corporal's  squad  to-day. 

A  factor  not  to  be  neglected  in  the  advancement  of  medical  science 
is  the  feeling  of  national  pride.  Most  of  the  medical  science  of  the 
past  and  much  of  the  current  knowledge  has  on  it  the  mark  "made 
in  Europe."  To-day  this  mark  is  occasionally  being  replaced  by  the 
label  "made  in  America,"  and  without  doubt  the  home  market  will 
soon  be  well  supplied.  Fortunately,  tariff  barriers  and  trusts  do  not 
interrupt  the  currents  of  knowledge.  Without  hindrance  we  have  filled 
our  storehouses  from  the  old  world  and  I  trust  that  we  may  repay  in 
due  time  sonie  of  our  huge  indebtedness.  Our  national  pride  once 
awakened  will  see  to  it  that  our  country,  the  wealthiest  in  material 
things,  shall  continue  to  give  as  well  as  to  receive  the  fruits  of  the 
intellect. 

These  are  forces  acting  chiefly  from  without.  Perhaps  the  most 
important  acting  from  within  has  been  the  use  of  animals.  The  study 
of  the  great  domain  of  infectious  diseases  has  revealed  such  a  similarity 
between  the  diseases  of  man  and  the  higher  animals  that  we  hesitate 
now  less  than  before  to  apply  courageously  the  knowledge  gained  in 
our  experiments  upon  the  highest  mammals  to  Jiuman  physiology  and 
pathology.  Without  this  aid  from  animal  life,  medicine  as  a  pro- 
gressive experimental  science  would  dwindle  into  insignificance. 
Moreover,  the  artificiality,  the  rigidity  and  awkwardness  of  the  medi- 
cine of  a  generation  ago  have  been  largely  dissipated  by  its  contact  with 
biology,  which  brought  with  it  the  comparative  point  of  view. 

Side  by  side  with  the  use  of  animals  we  may  place  the  convenient 
use  of  bacteria  and  other  microorganisms  in  our  laboratories  in  pro- 
ducing disease  as  one  of  the  great  levers  of  pathological  research  to-day. 
They  have  enabled  the  investigator  to  establish  important  centers  of 
research  completely  independent  of  and  coordinate  with  those  connected 
with  the  hospital  and  the  dead-house.  The  latter,  it  is  true,  still 
remain  a  final  court  of  appeal  for  all  discoveries  destined  for  the  relief 
and  cure  of  human  diseases. 

In  the  historical  development  of  science  the  research  instinct  ap- 
peared at  first  sporadically,  and  until  recently  it  was  simply  the  spon- 
taneous flowering  of  the  scholarly  mind  in  the  highest  institutions  of 
learning.     To-day  it  has  been  actually  organized  not  so  much  to  train 


MEDICAL    BESEAFCH  323 

youth  as  to  produce  useful  knowledge.  This  new  organization  of 
research  has  been  greatly  favored  by  the  promise  of  valuable  returns 
in  the  suppression  of  infectious  diseases  of  man  and  animals.  Most  of 
the  institutions  founded  thus  far  were  created  by  public  authority  for 
this  purpose.  It  was  realized  that  such  work  must  be  pushed  forward 
rapidly  to  secure  results  of  value  to  public  health  and  economy. 

About  twenty-five  years  ago  special  laboratories  began  to  appear. 
Our  own  government  figured  among  the  earliest  in  voting  what  were 
then  very  liberal  appropriations  for  the  study  of  infectious  animal 
diseases.  At  the  same  time  came  the  German  Imperial  Health  Office 
and  somewhat  later  the  Institute  for  Infectious  Diseases  in  Berlin,  and 
the  Pasteur  Institute  in  Paris;  more  recently  there  have  been  estab- 
lished the  Institute  for  Experimental  Therapy  in  Frankfort,  Germany, 
and  the  many  sero-therapeutic  institutes  and  public  health  labora- 
tories, nearly  all  of  which  have  become  noted  for  their  research  work. 
In  our  own  country  we  have  last  but  not  least  the  Eockefeller  Insti- 
tute for  Medical  Research  of  this  city  and  the  Memorial  Institute  for 
Infectious  Diseases  in  Chicago.  Most  of  these  were  created  to  deal 
scientifically  with  problems  of  immediately  practical  bearing.  But  it 
does  not  need  a  prophet  to  foresee  that  following  them  others  will  arise 
which  will  devote  themselves  to  broader  and  more  fundamental  prob- 
lems and  which  will  attack  those  left  unsolved  by  the  former  institu- 
tions. Of  this  latter  class  the  Pasteur  Institute  in  Paris  and  the 
Eockefeller  Institute  are  conspicuous  examples. 

The  founding  of  research  institutes  does  not  guarantee  their  success. 
That  will  depend  upon  the  men  who  work  in  and  for  them.  It  has 
become  evident  that  our  research  workers  must  have  more  diversified 
training  than  the  older  generation  possesses.  The  store  of  knowledge 
accumulated  by  science  must  be  made  available  to  medicine.  The  only 
way  in  which  this  can  be  accomplished  is  to  have  trained  men  continu- 
ally examining  and  testing  this  accumulating  store  of  facts  and  apply- 
ing them  to  the  problems  of  disease.  Such  men  should  have  medical 
training  and  approach  their  problems  from  the  medical  point  of  view ; 
but  to  them  should  be  spared  the  necessity  of  learning  ultimate  details 
of  the  medical  art  and  they  should  give  their  energy  to  some  sister 
study,  be  it  morphology,  physiology,  chemistry  or  pathology.  Medicine 
has  just  begun  to  realize  the  need  of  drawing  to  itself  the  great  talent 
which  hitherto  has  had  an  open  door  only  to  the  pure  and  applied 


324  MEDICAL   BESEABCH   AND   EDUCATION 

sciences.  Eesearch  is  largely  dependent  for  its  successful  pursuit  upon 
an  attitude  of  the  mind  which  insists  on  following  a  clew  that  promises 
to  reveal  some  relationship,  some  law  of  causality,  between  phenomena 
hitherto  apparently  unrelated.  This  type  of  mind  has  many  of  the 
attributes  of  the  inventor  who  is  attempting  to  combine  to  our  advan- 
tage the  forces  of  nature  in  new  and  unlooked-for  ways  and  to  express 
them  in  the  form  of  labor-saving  machines.  In  order  to  attract  these 
minds  we  must  pay  them  a  living  wage  and  provide  workshop  and  tools, 
and  exercise  but  moderate  restraint  over  their  activities.  To  them  the 
exterior  of  practical  medicine  has  a  forbidding  aspect.  We  must  bring 
them  to  face  its  really  wonderful  problems  through  the  portals  of  the 
laboratory. 

After  we  have  established  research  institutes  and  brought  together 
a  devoted,  enthusiastic  group  of  scientists  we  must  not  look  too  closely 
at  the  immediate  practical  value  of  research.  Most  of  the  epoch- 
making  discoveries  have  had  little,  if  any,  direct  influence  on  medical 
practise  at  the  start  and  even  for  some  time  after.  Some  have  wholly 
failed  to  yield  hoped-for  results,  but  they  have  had  great  influence  in 
unexpected  directions.  This  is  chiefly  because  great  discoveries  are 
as  a  rule  not  ripe  for  use.  To  point  out  a  hitherto  unrecognized  cause 
does  not  thereby  enable  us  to  overcome  its  "effects.  These  may  be 
grounded  in  centuries  of  adaptation.  A  great  discovery  frequently 
does  no  more  than  call  attention  to  a  new  fact  without  defining  its 
relationships.  The  discovery  of  the  tubercle  bacillus  for  example  left 
the  whole  question  of  its  complex  relation  to  a  given  host  untouched. 
The  same  may  be  said  for  most  other  microbes.  The  delicate  equilib- 
rium between  parasite  and  host  is  the  thing  to  be  worked  out  before 
we  can  rationally  proceed  to  upset  it  in  our  favor.  There  is  therefore 
no  need  of  hurrying  to  put  discoveries  to  use.  Many  are  discredited 
because  of  such  ill-advised  attempts  and  the  investigator  himself  be- 
comes discouraged  in  the  futile  effort  to  apply  principles  which  fit  only 
in  part  the  practical  condition  to  be  influenced. 

The  tendency  to  make  research  directly  prove  pet  theories,  find 
short  cuts  to  health,  and  cure  diseases  hitherto  unsuccessfully  treated 
will  continue  to  give  the  investigator  trouble  for  some  time  to  come. 
What  is  needed  is  that  at  least  a  small  number  of  scientists  work  at 
these  problems  of  disease  as  we  would  at  the  other  phenomena  of  the 
world  around  us.      They  should  look  them  over  from  all  sides  calmly 


MEDICAL   BESEAECH  325 

and  objectively  to  get  at  the  lessons  expressed  in  them.  They  should 
look  upon  pathological  manifestations  as  the  normal  sequences  of 
causes  operating  under  special  conditions  and  for  certain  periods  of 
time.  They  should  endeavor  to  analyze  phenomena  rather  than  attempt 
to  suppress  or  crush  them.  That  function  should  belong  to  the  health 
officer  and  the  practising  physician. 

In  order  to  take  this  calm  attitude  toward  disease  as  a  natural 
phenomenon  and  attempt  to  explain  it^  it  may  be  necessary  to  move 
backward  toward  simpler  problems  from  man  to  the  higher  animals, 
from  these  to  lower  types,  from  the  complex  processes  of  the  human 
machine  to  the  physical  and  chemical  phenomena  of  the  inorganic 
world.  This  has  not  always  been  the  attitude  of  medicine,  for  stand- 
ing as  it  does  under  the  too  near  and  impending  shadow  of  suffering 
and  death,  it  was  but  natural  to  attack  the  most  difficult  and  complex 
problems  first. 

It  is  needless  to  say  that  the  position  of  the  research  worker  of  the 
immediate  future  will  not  be  an  easy  one.  The  strain  to  produce  some- 
thing is  far  more  wearing  than  teaching.  The  mental  play  of  the 
teacher's  mind  to  produce  something  is  relaxation  compared  with  that 
of  the  investigator  to  carry  out  a  contract  for  the  delivery  of  new 
knowledge.  The  gap  of  years  and  even  generations  may  yawn  between 
the  problem  in  hand  and  actual  solution.  It  may  indeed  prove  to  be 
wholly  impregnable  from  the  point  of  attack.  It  may  be  solved  by 
some  obscure  genius  with  slight  facilities  who  happens  to  hit  the 
combination  which  unlocks  the  secret. 

"We  have  all  experienced  the  burden  and  complexity  of  growing 
information  which  has  not  reached  the  stage  of  actual  knowledge. 
Extensive  tables  of  figures  are  laboriously  built  up  around  it  and  the 
worker  himself  becomes  encrusted  and  almost  asphyxiated  with  methods 
and  technicalities.  We  find  the  laboratory  growing  hot  and  stifling  as 
we  painfully  add  one  more  fact  to  the  heavy  burden.  Suddenly  and 
quite  unexpectedly  the  true  discoverer  comes  with  a  simple  explanation. 
At  his  approach  the  air  is  cleared  and  freshened.  Tables  and  figures 
are  shoved  to  one  side,  and  we  begin  our  work  once  more  with  improved 
vision  along  another  road. 

Such  is  frequently  the  mission  of  the  true  discoverer,  to  leap  over 
mounds  of  facts  and  figures,  bring  us  back  close  to  nature  and  show 
us  that  her  movements  are  often  far  simpler  than  we  dared  imagine. 


326  MEDICAL   BESEABCH   AND   EDUCATION 

Thus  far  I  have  dealt  with  research  as  a  thing  by  itself  to  be 
furthered  by  endowment  and  prosecuted  by  specially  fitted  men  for  the 
sake  of  its  value  to  mankind  This  is  only  preliminary,  however,  to 
the  main  thesis  of  our  remarks,  the  training  of  research  workers  and 
the  relation  of  research  to  the  medical  school.  As  a  humble  representa- 
tive of  the  school  which  has  provided  so  liberally  in  its  new  buildings 
for  both  research  and  instruction  I  must  endeavor,  amid  the  tangle  of 
changing  conditions,  to  place  before  you  the  relation  between  teaching 
and  research  as  it  presents  itself  to  me. 

I  am  quite  inclined  to  make  a  sharp  distinction  between  the  physi- 
cian and  the  investigator,  and  I  think  the  time  has  come  to  create  as 
it  were  a  separate  genus.  What  may  be  said  of  the  type  research  worker 
should  also  apply  to  the  teacher.^ 

Some  enthusiasts  would  go  so  far  as  to  urge  that  all  students  be 
made  research  workers.  This  is  clearly  uneconomical,  for  not  many 
are  fitted  and  the  world  has  no  use  for  many.  There  are  needed  chiefly 
well-educated,  humane,  ujDright  and  patient  workers  who  are  ready  to 
do  the  routine  tasks  of  their  profession.  The  physician  must  keep  step 
with  the  great  procession  as  it  slowly  moves  forward.  He  can  not  devi- 
ate much  to  the  right  or  to  the  left  nor  move  much  faster  than  the  rest. 
His  activities  are  more  or  less  defined  by  a  consensus  of  opinion.  No 
matter  how  much  he  may  swing  his  pinions  in  the  laboratory,  they  will 
have  but  little  room  to  move  in  the  practical  work  of  life.  It  is  one 
thing  to  discover,  and  another  to  apply,  one  thing  thoroughly  to  believe 
in  our  results,  another  to  make  others  believe  and  act  accordingly. 

The  research  worker  on  the  other  hand  deals  more  with  the  unde- 
fined boundaries  of  knowledge  and  with  the  frayed  edges  of  sound  in- 
formation. He  does  not  march  with  the  procession,  but  he  must  do 
lonely  outpost  and  scouting  duties.  He  must  seek  clandestine  meet- 
ings with  those  of  other  sciences,  for  he  learns  mainly  by  breaking 
through  conventional  barriers.  He  makes  his  discoveries  unknown  to 
others,  and  the  farther  they  are  in  advance  of  the  times  the  less  atten- 
tion they  will  receive. 

^  The  time  is  not  so  distant  when  it  will  become  necessary  to  separate  the 
functions  of  teaching  and  research.  The  teacher  will  then  investigate  to  im- 
prove his  teaching,  the  investigator  will  teach  to  clarify  the  aims  of  research. 
One  merges  insensibly  into  the  other.  The  attempt  to  set  apart  the  teacher 
and  investigator  is  simply  another  tributary  of  the  current  which  is  tending 
to  make  all  teachers  independent  of  the  practise  of  medicine,  by  urging  adequate 
compensation  for  their  entire  time. 


MEDICAL   BESEAUCH  327 

Again,  the  physician  under  the  stress  of  practical  life  must  be  posi- 
tive and  aggressive  in  his  dealing  with  disease.  He  must  supply  em- 
pirically what  is  lacking  rationally,  and  his  experience  is  therefore  of 
the  greatest  value  as  it  is  in  all  vocations  which  couple  science  with 
actual  life.  The  investigator,  on  the  other  hand,  must  be  to  a  certain 
degree  negative,  skeptical  of  current  theories,  and  suspicious  of  mere 
experience.  He  must  frequently  destroy  before  he  builds  up.  He  ap- 
proaches the  individual  case  of  disease  through  general  laws  established 
through  experiment.  The  physician  must  begin  with  his  patients  and 
through  them  reach  general  formulae  governing  disease.  He  studies 
the  patient,  whereas  the  investigator  studies  the  disease. 

The  investigator  should  be  free  to  a  certain  degree  to  create  his 
material  and  his  problems.  The  physician  must  accept  his  cases  as 
they  come  to  him  and  he  can  only  exercise  the  skill  of  selection.  Each 
patient  is  indeed  a  problem,  but  it  is  worked  out  under  the  illumina- 
tion of  the  accumulated  knowledge  of  the  world,  and  not  dealt  with 
according  to  strange  and  hitherto  unlmown  formulae.  The  physician 
can  not  control  his  patient  excepting  within  a  narrow  range.  Experi- 
ment as  such,  except  when  of  a  trivial  nature,  is  forbidden  by  law  and 
conscience.  Statistics  is  the  only  court  of  appeal  he  has  in  attempting 
to  prove  success,  and  this  method  we  know  is  open  to  serious  error.  On 
account  of  his  peculiar  and  unique  life  work,  the  physician  must  build 
his  education  as  broadly  as  possible  and  carry  as  much  information  as 
is  compatible  with  normal  thinking.  The  research  worker,  on  the  other 
hand,  digs  and  delves  and  he  must  leave  unnecessary  encumbrances 
behind. 

The  main  task  of  the  medical  schools  will  always  be  to  train  physi- 
cians. It  does  not  fall  within  the  scope  of  this  address  to  define  what 
this  training  should  be,  and  I  shall  not  attempt  it,  excepting  in  so 
far  as  it  bears  upon  laboratory  instruction.  I  believe  that  the  medical 
school  should  make  the  future  physician  absorb  as  much  as  possible  of 
the  best  medical  science  of  the  day  and  give  him  a  certain  initial  skill 
and  dexterity  in  carrying  out  the  fundamental  operations  of  the  med- 
ical art.  The  power  of  the  student  to  think  independently,  to  digest 
the  facts  he  has  absorbed  into  some  current  theory  which  enables  him 
to  absorb  more,  and  thus  continually  upbuild  and  rebuild  his  science, 
should  be  uninterruptedly  stimulated  by  lectures,  conferences  and 
reading.     To  aid  this  constructive  work  laboratories  have  come  quite 


328  MEDICAL   EESEABCH   AND   EDUCATION 

generally  into  use.  They  are  not  research  institutes  at  bottom,  but 
originally  a  means  to  fix  and  illuminate  through  the  senses  facts  other- 
wise meaningless.  For  the  average  student  the  laboratory  is  a  review 
as  well  as  a  fixative  of  data  which  he  is  to  carry  with  him  and  upon 
which  he  is  to  build  his  professional  experience. 

Those  who  are  inclined  to  claim  for  the  laboratory  more  than  this 
in  the  education  of  the  physician,  I  would  ask  to  consider  how  little 
of  medical  science  can  actually  be  presented  there  to  the  student.  Cer- 
tain functions  can  be  demonstrated  in  physiology,  certain  processes  and 
products  in  chemistry,  certain  anatomical  facts  and  certain  parasites  as 
etiological  factors  in  pathology.  The  prolonged  impact  of  untoward 
conditions,  the  silent  movement  from  health  to  disease,  the  shadowy 
boundary  between  the  two  who  can  adequately  demonstrate  them  in 
the  laboratory.  There  the  days,  months  and  years  of  disease  processes 
must  be  concentrated  into  minutes  and  hours.  Much  of  the  laboratory 
work  is  like  the  ward  visit,  a  fragment,  to  be  pieced  out  through  the 
agency  of  books,  lectures  and  the  imagination. 

I  am  of  course  fully  aware  of  the  great  importance  of  thoroughly 
training  the  senses  and  the  powers  of  observation.  The  chief  means 
of  communication  of  the  physician  with  his  patient  is  through  the 
medium  of  the  senses,  and  the  more  avenues  of  intercourse  are  opened 
between  him  and  the  diseased  body  by  increased  delicacy  of  sense  per- 
ceptions and  by  instruments  of  precision  which  aid  and  control  the  sense 
impressions,  the  more  precise  the  diagnosis. 

Lest  I  be  misunderstood,  I  wish  to  emphasize  the  importance  of 
bringing  the  student  who  is  to  be  the  future  practitioner  in  as  close 
contact  with  laboratory  research  and  its  immediate  fruits  as  possible. 
For  he  will  be  the  one  to  apply  new  points  of  view,  gained  experimen- 
tally, in  the  prevention  and  treatment  of  disease.  Unless  he  gains  some 
confidence  in  the  laboratory  and  its  methods  and  is  ready  to  welcome 
its  fruits  how  can  medicine  make  any  progress  ?  His  own  contact  with 
the  laboratory  should  be  for  him  a  strong  support  and  create  in  him 
faith  in  the  ultimate  triumph  of  science  over  the  problems  and  mys- 
teries of  disease.  Its  influence  should  reach  far  beyond  his  years  of 
training.  When  in  practise  he  is  disturbed  by  the  confusion  of  voices, 
which,  like  the  will-o'-the-wisp,  lead  neither  here  nor  there,  or  when 
he  is  perplexed  by  the  movement  of  fads  and  fashions  pointing  now  in 
one,  now  in  the  diametrically  opposite  direction,  when  he  comes  to  real- 


MEDICAL   BESEABCH  329 

ize  that  much  of  his  professional  work  is  still  empiricism  and  that  it 
moves  from  precedent  to  precedent,  he  will  look  back  upon  his  best  lab- 
oratory work  with  a  feeling  of  relief  and  recognize  in  it  the  germs  of  the 
science  where  his  results  came  true  if  he  worked  accurately,  and  where 
he  could  predict  the  outcome.  This  power  to  predict  which  character- 
izes science  should  stimulate  the  trained  physician  to  urge  on  in  every 
way  his  profession  toward  the  scientific  ideal.  If  the  laboratory  suc- 
ceeds in  creating  a  desire  to  aid  in  realizing  in  the  student  this  ideal  its 
work  will  be  well  done.  This  craving  to  place  his  profession  on  a  more 
and  more  scientific  basis  will  lead  to  steady  intellectual  growth  and  in- 
sight and  a  proper  receptive  attitude  toward  the  progress  of  science. 

Much  confusion  can  be  avoided,  I  think,  by  classifying  laboratories 
into  two  categories,  those  that  inculcate  principles  of  medical  science 
and  those  which  subserve  clinical  diagnosis.  In  the  latter,  clinical 
medicine  or  medical  practise  seeks  to  lay  hold  of  the  acquisitions  of 
experimental  science  and  to  utilize  them  in  the  interpretation  of 
symptoms.  The  clinical  or  hospital  laboratory  approaches  medical 
problems  from  the  professional  side  and  is  thus  an  extension  of  med- 
ical practise  into  a  territory  where  science  and  practise  meet  and  shade 
into  one  another.  Here  the  future  physician  should  receive  most  care- 
ful training  when  he  begins  to  direct  his  studies  toward  some  branch 
of  medicine.  For  this  important  stage  the  Harvard  Medical  School 
has  left  the  fourth  year  open.  In  this  year  the  student  should  utilize 
all  possible  means  of  combining  his  practical  training  with  the  more 
analytic  methods  of  the  laboratory  and  exploit  whatever  it  may  offer 
in  more  accurate  methods  of  making  and  recording  observations.  At 
the  same  time,  we  must  not  make  the  mistake  of  calling  this  research. 
It  may  later  on  shade  into  research,  but  it  is  at  first  simply  increasing 
and  perfecting  the  means  of  identifying  already  well-known  disease 
processes. 

"We  are  just  now  passing  through  a  period  of  reaction  against  so- 
called  book  learning  which  is  likely  to  lead  us  too  far  in  the  other 
direction.  So  much  weight  has  been  placed  upon  the  training  of  the 
senses  that  we  are  in  danger  of  neglecting  the  mind  behind  them.  It 
is  vaguely  assumed  by  some  that  laboratory  work  is  per  se  research. 
This  is  far  from  the  truth.  We  might  with  profit  carry  on  researches 
in  the  published  work  of  others  without  entering  the  laboratory.  We 
might,  on  the  other  hand,  spend  our  whole  life  in  a  laboratory  without 


330  MEDICAL   BE  SEARCH   AND   EDUCATION 

acquiring  more  than  a  little  manual  and  optical  dexterity.  We  are  in 
danger  of  forgetting  that  the  training  of  the  observational  powers  is 
simply  developing  another  language  made  necessary  by  the  expansion 
of  medicine  as  a  biological  science.  The  true  investigator  may  have 
but  imperfectly  trained  senses,  but  he  may  still  succeed  in  discover- 
ing and  opening  up  a  new  country  to  us.  With  his  intellectual  power 
to  grasp  and  arrange  data,  largely  worked  out  by  others,  perhaps,  he 
finds  his  way  through  the  unknown. 

In  our  zeal  to  further  the  educational  methods  of  the  day,  there 
is  just  as  much  danger  that  we  overload  the  mind  with  too  many  sense 
impressions,  as  with  too  many  facts  gathered  through  the  medium  of 
books.  Have  we  not  heard  of  the  absurd  waste  of  time  in  some  labora- 
tories over  work  employing  laboratory  technique  which  is  as  empty  as 
the  written  page  to  many  a  student?  Have  we  not  seen  many  a  lab- 
oratory servant  whose  senses  were  sharper  than  ours  on  occasion ;  many 
a  butcher  who  detected  abnormalities  of  the  tissues  more  quickly  than 
we  ?  Yet  they  were  not  "  doing  research."  Let  us  not  deceive  ourselves 
concerning  the  true  inwardness  of  research.  It  does  not  consist  in 
trained  senses  alone.  It  is  a  quality,  an  attitude  of  the  intellect  work- 
ing through  the  senses.  Claude  Bernard  clearly  recognized  this  when 
he  said :  "  He  who  does  not  know  what  he  is  looking  for  will  not  lay 
hold  of  what  he  has  found  when  he  gets  it." 

Though  research  may  be  carried  on  and  is  going  on  in  all  depart- 
ments of  medicine  to-day,  yet  the  true  home  of  the  investigator  is  the 
modern  laboratory.  Here  we  have  a  kind  of  reproduction  in  minia- 
ture of  the  actual  field  of  work,  where,  by  means  of  physical,  chemical 
and  biological  methods  of  analysis,  the  problem  in  hand  may  be  re- 
duced to  as  simple  terms  as  possible  or  at  least  confined  within  more 
or  less  governable  conditions.  When  it  has  reached  a  certain  stage 
of  maturity,  then  facilities  should  be  at  hand  which  enable  the  in- 
vestigator to  approach  cautiously  the  very  complex  conditions  of  actual 
disease  in  the  hospital  and  its  special  laboratories. 

The  university  medical  school  has  thus  two  duties  to  perform,  to 
train  practical  men,  physicians  and  health  officers,  and  to  encourage 
the  few  who  incline  to  research.  The  methods  of  training  for  both 
coincide  for  a  large  part  of  the  course,  but  they  must  eventually  diverge, 
the  practical  man  to  enter  the  actual  field  of  conflict  with  disease  and 
forge  his  weapons  as  well  as  he  can  from  the  storehouse  of  the  world's 


MEDICAL   SESEAJRCE  331 

accumulated  experience  and  science,  the  investigator  to  continue  his 
struggle  with  the  stubborn  and  evasive  facts  of  nature. 

To  carry  out  this  program  the  university  school  must  have  teachers 
who  are  investigators,  well-equipped  laboratories  both  for  large  classes 
and  for  individual  advanced  workers.  It  must  have  satisfactory 
operating  rooms  and  stables  for  small  and  large  animals,  for  the  ex- 
perimental and  observational  study  of  animal  diseases  is  the  logical 
outcome  of  laboratory  research.  It  is  another  intermediate  station  on 
the  way  to  human,  pathology.  It  frequently  presents  such  strikingly 
clear  solutions  of  difficult  problems  and  permits  us  to  introduce  the 
comparative  method  which  has  been  so  fruitful  in  the  biological  sci- 
ence. Closely  associated  with  the  school  should  be  hospitals  and  clin- 
ical laboratories.    Let  us  look  at  a  few  of  these  requisites  very  briefly. 

The  training  and  encouragement  of  research  as  well  as  thorough 
teaching  in  our  medical  schools  lead  by  implication  to  the  doctrine  that 
professors  should  be  investigators  themselves.  For  the  purpose  of  ele- 
mentary class  work  it  may  be  maintained  that  it  is  enough  for  teach- 
ers to  instruct  with  the  aid  of  all  the  paraphernalia  of  the  day.  But 
what  shall  they  teach?  Shall  they  go  no  faster  than  the  successive 
editions  of  text-books  allow,  or  shall  they  express  an  opinion  about 
or  actually  teach  the  newest  doctrines?  As  I  stated  before,  the  knowl- 
edge of  the  world  is  covered  with  the  froth  of  research  fermentation  of 
several  years'  depth,  and  the  latter  yields  about  as  much  genuine 
knowledge  as  the  froth  does  actual  fluid.  The  teacher  can  not  well 
sound  its  depths  unless  he  has  made  some  independent  studies  of  his 
own.  Then  he  will  be  able  to  say  something  definite,  whether  he  has 
been  at  work  in  this  very  field  or  not.  His  critical  view  will  enable  him 
to  take  sides  and  be  positive  rather  than  negative  in  his  teaching. 

It  will  no  doubt  be  maintained  by  many  that  to  teach  undergrad- 
uates the  latest  information  is  out  of  place  or  at  any  rate  not  neces- 
sary. All  that  they  need  for  their  daily  subsistence  pertains  to  funda- 
mental conceptions.  But  I  answer  that  we  really  know  little  of 
fundamental  conceptions  and  what  we  believe  we  know  is  being  affected 
and  modified  by  every  new  discovery  of  any  value.  It  is  of  the  utmost 
importance  that  the  theories  which  the  graduate  takes  with  him  be  as 
sound  and  withal  as  fresh  as  the  teacher  can  make  them,  for  they  will 
form  the  scaffolding  of  his  thinking  for  some  time  to  come,  possibly  for 
many  years. 


332  MEDICAL   BESEABCH   AND   EDUCATION 

The  teacher  who  is  called  upon  to  direct  the  work  of  students  who 
are  beginning  to  feel  their  way  into  unknown  territory  or  who  have 
already  left  the  beaten  path  far  behind  must  of  necessity  be  an  in- 
vestigator. Without  going  ahead  of  them  himself  his  counsel  is  apt  to 
be  wavering  and  at  times  he  feels  himself  wholly  helpless  to  advise. 
In  other  words,  to  direct  research  the  teacher  must  be  playing  the  chief 
part  while  his  students,  of  whatever  rank,  should  take  subordinate  parts 
all  definitely  working  toward  a  given  end.  Only  by  such  cooperative 
coordinated  work  can  both  the  worker  and  the  task  become  a  success. 
The  teacher's  capacity  for  research  is  not  necessarily  measured  by  his 
productivity.  This  may  be  curtailed  by  his  high  standards  of  what 
should  be  put  on  record.  At  the  same  time  his  capacity  for  research 
should  somehow  make  itself  felt  through  those  whose  labors  he  is  di- 
recting. His  fruitfulness  should  be  manifested  through  them.  If  a 
teacher  remains  sterile  both  in  himself  and  his  students  he  has  missed 
his  vocation. 

Of  importance  equal  to  that  of  an  efficient  body  of  teachers  are 
adequate  laboratory  facilities  for  both  teaching  and  research.  Med- 
ical science  has  moved  beyond  that  stage  when  a  student  could  be  kept 
profitably  employed  with  a  microscope  and  a  box  of  slides.  "With  the 
growth  of  laboratory  methods  of  diagnosis,  more  varied  and  costly 
apparatus  is  needed,  more  space  to  place  it  and  more  laboratory  service 
to  guard  it. 

In  research  the  demands  are  similar,  but  more  exacting  in  certain 
directions.  Some  still  believe  that  abundant  space  and  work  room  with 
cases  full  of  the  latest  instruments  will  certainly  lead  to  great  discov- 
eries. These  are,  to  be  sure,  necessary;  but  without  the  motive  power 
behind  them  are  more  than  barren;  they  create  the  debts  rather  than 
the  assets  of  research.  This  motive  power  consists  of  enough  assured 
income  to  carry  on  research  and  develop  the  research  powers  of  meri- 
torious students.  There  should  also  be  ample  means  for  laboratory 
service.  Eesearch  is  in  one  sense  a  business,  the  laboratory  a  workshop. 
Here  all  sorts  of  processes  are  under  way  and  as  no  one  would  expect  a 
workshop  to  be  carried  on  with  only  a  foreman,  so  a  laboratory  can 
not  be  kept  in  use  without  laboratory  service.  Hitherto  assistants  have 
been  made  the  motive  power  and  the  laborers;  but  this  system  should 
no  longer  be  maintained.  Not  only  is  it  wasteful  to  fill  the  time  of  as- 
sistants with  routine  manual  labor,  but  it  is  wasteful  in  so  far  as  the 


MEDICAL   BESEAECE  333 

laboratory  is  dismembered  at  the  end  of  each  year.  Every  laboratory 
should  be  in  working  order  even  if  all  assistants  are  lacking.  The 
trained  laboratory  servant  should  represent  the  routine  and  conserva- 
tive, the  assistants  and  investigators  the  progressive,  element. 

With  the  growth  of  the  cost  of  research  it  becomes  of  great  impor- 
tance to  exercise  care  and  selection  in  admitting  men  to  research  posi- 
tions. Fortunately  there  are  not  many  collateral  attractions  in  a  life 
of  research  and  the  process  of  elimination  acts  as  a  rule  automatically. 
Still  there  is  danger  just  now  that  some  of  the  flotsam  and  jetsam 
caught  in  an  eddy  or  else  afraid  of  the  current  of  practical  life  may 
seek  the  quiet  of  the  laboratory,  because  of  some  imagined  taste  or 
capacity  which  fails  to  materialize  later  on.  It  is  far  better  not  to  have 
any  research  workers  than  poor  ones. 

The  leaven  of  research  which  has  so  completely  permeated  and 
revolutionized  all  doctrines  and  practises  of  medicine  in  the  past 
quarter  century  is  still  acting  and  no  one  can  foretell  how  it  is  going 
to  mold  the  medical  science  and  practise  of  the  coming  decades.  No 
one  can  foresee  what  it  is  going  to  do  with  the  medical  schools. 

There  will  come  without  doubt  much  change  in  the  artificial  boun- 
daries of  the  present  so-called  departments.  Created  for  purposes  of 
teaching  and  administration,  they  are  a  veritable  bane  to  the  investi- 
gator who  can  not  stop  mining  because  his  vein  happens  to  dip  into 
another  man's  superficial  territory.  Even  in  the  routine  of  teaching 
many  changes  are  lilcely  to  come.  I  believe  there  will  be  developments 
in  two  main  directions.  The  present  laboratory  studies,  or  pro- 
paedeutics, will  be  deepened  and  extended  in  the  direction  of  the  more 
exact  sciences,  or  toward  the  physical,  chemical  and  biological  work 
of  the  university  proper.  As  a  necessary  result  of  this  movement  much 
of  the  work  now  done  by  these  departments  will  move  forward  into 
clinical  medicine  and  surger}',  and  there  will  be  a  corresponding  growth 
and  strengthening  of  the  clinical  and  pathological  laboratories  of  the 
hospitals.  To  illustrate:  Much  of  what  is  taught  to-day  in  pathology 
belongs  to  clinical  medicine  and  surgery,  for  it  is  largely  special  and 
diagnostic  in  character.  The  pathologist  is  now  the  servant  of  the 
physician  and  surgeon  in  completing  and  rectifying  their  diagnoses. 
The  pathologist  of  the  future  will  deal  with  more  general  phenomena 
derived  from  experimental  and  comparative  data,  just  as  the  physi- 
ologist has  moved  onward,  or  backward  if  you  please,  into  general  and 


334  MEDICAL   BESEABCH   AND   EDUCATION 

comparative  physiology.  Similarly,  the  burden  of  other  new  scientific 
departments  will  be  shifted  into  the  more  practical  branches  to  make 
way  for  more  fundamental  problems.  The  logical  outcome  of  such 
a  rearrangement  of  studies  would  be  eventually  a  college  course  ar- 
ranged wholly  with  a  view  toward  medicine  and  sanitary  science,  in 
which  the  bulk  of  the  present  early  studies  of  the  medical  schools 
would  find  a  place,  and,  secondly,  a  practical  course  in  medicine, 
surgery  and  sanitary  science,  in  which  clinical,  hospital  and  public 
health  laboratories  would  take  a  prominent  part.  It  may  be  that  in 
this  way  the  time  and  energy  of  the  student  aiming  for  two  degrees  and 
a  livelihood  could  be  saved,  while  the  efficiency  and  scope  of  the  course 
could  be  increased  at  the  same  time. 

The  establishment  of  research  institutes  by  governmental  authority 
and  private  munificence  marked  the  beginning  of  a  new  epoch  in  med- 
ical science  by  organizing  research  and  giving  it  an  assured  status. 
The  influence  of  these  institutes  upon  research  in  the  university  medical 
schools  will  be  watched  with  much  interest.  Unless  the  latter  take  a 
more  definite  position  and  furnish  opportunity  whereby  investigations 
of  a  more  serious  and  exhaustive  scope  may  be  undertaken,  the  research 
institutes  will  absorb  the  best  men  and  the  highest  class  of  work  and 
leave  research,  as  heretofore,  a  by-product  of  the  sthools,  often  desultory, 
discontinuous  and  trivial.  To  avoid  this  impending  calamity,  the  pro- 
fessors should  be  relieved  of  various  routine  duties  incidental  to  the 
management  of  laboratory  workshops.  There  should  also  be  appointed 
investigators  of  definite  rank  whose  teaching  should  be  subordinated 
to  research  in  such  a  way  that  the  latter  will  not  be  seriously  impaired 
by  long  interruptions. 

In  conclusion  I  wish  to  dwell  briefly  upon  a  phase  of  our  subject 
which  is  perhaps  the  most  important  of  all  and  toward  which  the 
various  lines  of  our  discourse  have  been  converging. 

The  relatively  large  endowments  given  to  medical  education  and 
research  in  recent  years  have  created  as  it  were  a  trust  to  be  adminis- 
tered by  the  medical  profession  in  the  interest  of  human  society  in 
the  broadest  and  highest  significance  of  the  term.  This  I  interpret 
to  mean  that  we  must  endeavor  to  make  all  advance  in  our  knowledge 
of  health  and  disease  common  property  so  far  as  this  may  be  possible, 
to  disseminate  broadcast  the  benefits  of  research  into  the  laws  of  healthy 
so  that  they  may  enter  into  and  form  an  integral  part  of  the  life  of  the 


MEDICAL   SESEAJRCE  335 

individual  and  the  community.  \\^e  all  know  that  much  of  the  daily 
work  of  the  physician  goes  to  charity,  that  the  public  health  authori- 
ties and  sanitary  officers  are  but  scantily  compensated  for  their  arduous 
and  often  dangerous  labors.  There  can  be  no  question  that  as  a  pro- 
fession medicine  stands  at  the  head  in  disinterested  service;  but  there 
is  still  room  for  improving  the  relation  between  medicine  and  the  pub- 
lic.   How  can  this  be  done? 

Perhaps,  next  to  the  education  of  physicians  of  the  highest  stand- 
ards, the  immediate  duty  of  the  university  medical  school  is  the  de- 
velopment through  research  of  preventive  medicine  and  sanitary  science 
and  the  education  of  sanitary  officers.  This,  it  seems  to  me,  is  the  best 
way  in  which  our  debt  to  society  can  be  discharged ;  for  it  is  the  way 
through  which  medicine  has  moved  during  the  past  quarter  century 
to  its  present  commanding  position;  it  is,  in  fact,  the  way  of  least  re- 
sistance for  the  human  race  to  evade  or  mitigate  the  penalty  incidental 
to  advancing  civilization.  Preventive  medicine  is  the  application  of 
medical  science  to  the  mass  as  well  as  to  the  individual.  It  attempts  to 
arrest  disease  before  its  momentum  has  carried  it  beyond  the  means  of 
help.  It  is  the  truly  modern  as  contrasted  with  the  medieval  point 
of  view. 

ISTobody  will  deny  that  much  has  already  been  done  in  the  de- 
velopment of  preventive  medicine  and  sanitary  science.  It  will  be 
claimed,  and  with  justice,  that  more  has  been  done  than  the  public  is 
willing  and  prepared  to  accept  and  live  up  to.  We  know  that  to-day 
municipalities  continue  to  permit  the  unnecessary  sacrifice  of  lives 
to  epidemic  disease,  that  politics  is  permitted  to  disorganize  efficient 
boards  of  health  in  large  and  small  communities  and  to  put  the  best 
material  interests  of  family  and  social  life  into  untrained  hands.  "We 
know  that  the  public  continues,  in  spite  of  warnings,  to  consume 
noxious  drugs,  widely  and  boldly  advertised  in  the  daily  press.  These 
difficulties  are  very  real,  but  they  should  not  discourage  us.  The  med- 
ical profession  is  in  a  sense  to  blame  for  this  condition ;  for  the  house- 
hold remedies  and  cures  of  to-day  are  those  of  the  doctor  of  a  genera- 
tion ago,  and  the  medical  practise  of  to-day  will  crop  out  in  the  daily 
life  of  the  next  generation.  Likewise,  the  indifference  of  the  physician 
and  health  officer  of  a  generation  ago  is  reflected  to-day  in  the  attitude 
of  the  mass  of  the  people. 

The  university  medical  school  has  here  a  great  function  to  perform. 


336  MEDICAL   SESEABCH   AND   EDUCATION 

for  it  is  the  legitimate  source  of  knowledge  pertaining  to  hygiene  and 
sanitation.  There  are  few  problems  which  have  not  been  suggested 
by  contact  with  disease.  Sanitary  science  is  broad  and  rests  upon  many 
foundations,  and  the  means  of  disseminating  its  teachings  are  many, 
but  its  origin  is  in  pathology.  Without  the  stimulus  of  the  continual 
presence  of  disease  its  problems  may  become  trivial  and  its  practise 
ineffective. 

The  university  medical  school  may  in  still  another  way  hasten  the 
diffusion  of  sounder  views  concerning  health  and  disease  by  creating 
more  interest  among  the  educated  in  the  general  problems  of  pathol- 
ogy. This  is  but  the  obverse  of  physiology,  and  its  principles,  once 
scientifically  founded  and  objectively  developed  along  general  and  com- 
parative lines,  should  form  an  attractive  study  in  all  biological  labora- 
tories. We  are  still  some  distance  from  the  realization  of  this  sugges- 
tion, but  the  task  is  worthy  of  the  best  men  in  our  best  schools. 

If  we  take  this  broad  view  of  the  work  of  the  university  medical 
school  and  try  to  put  it  into  effect,  medical  science  will  come  out  of 
its  somewhat  isolated  position  and  take  its  proper  place  beside  the  other 
sciences.  The  work  of  the  physician  will  then  be  rated  more  justly, 
because  the  great  complexity  of  the  problem  of  health  and  disease  will 
be  more  appreciated.  His  services  will  then  be  sought  more  frequently 
before  rather  than  during  the  calamity  of  illness,  because  it  will  be 
better  understood  why  he  can  more  easily  forestall  and  prevent  than 
cure  disease. 


THE   OUTLOOK  IN   MEDICIXE  ^ 

By  G.  N.  Stewaet,  A.M.,  M.D.,  Sc.D.,  D.P.H., 

Professoe  of  Experimental  Medicine  and  Director  of  the 
Gushing  Laboratory,  "Western  Eeser\'e  University 

It  has  once  or  twice  before  fallen  to  my  lot  to  address  the  freshmen 
at  the  opening  of  the  session  in  other  universities.  But  I  believe  that 
this  is  the  first  occasion  on  which  I  have  essayed  the  more  formidable 
task  of  speaking  to  a  graduating  class.  I  feel  it  is  a  more  formidable 
task.  The  freshman  is  young  and  ingenuous,  not  hypercritical,  dis- 
posed to  be  pleased,  and  upon  the  whole  if  anything  rather  too  prone  to 
believe  that  his  teachers  must  know  a  great  deal  more  than  himself.  I 
remember  once  asking  a  colleague  what  subject  he  would  suggest  for  a 
talk  at  the  opening  of  a  certain  medical  school,  a  talk  which  was  to  be 
directed  chiefly  to  freshmen.  He  replied,  "  "^liy,  almost  anything  will 
do,  only  morality  and  good  advice  have  been  rather  overdone  of  late." 
I  do  not  know  what  the  present  condition  of  the  market  for  morality 
and  advice  may  be  here,  nor  whether  the  demand  may  be  greater  among 
graduates  than  among  freshmen,  but  in  any  case  I  do  not  feel  any 
special  call  to  assume  the  roll  of  moralist  or  counselor.  It  occurred  to 
me,  however,  that  it  might  be  of  some  little  interest  to  those  who  have 
just  been  admitted  within  the  portals  of  our  ancient  and  world-wide 
profession  to  hear  from  one  who  has  now  been  a  member  of  it  for  well- 
nigh  twenty  years,  whose  studies  were  carried  on  under  different  con- 
ditions and  under  a  different  sky  from  yours  (not  on  the  sunny  banks 
of  the  Mississippi,  but  by  the  gray  shores  of  the  Firth  of  Forth  in  far- 
off  Edinburgh),  a  few  words  on  the  changes  and  the  contrasts  which 
those  years  have  brought,  the  tendencies  they  have  developed  and  the 
vistas  they  have  opened  up  for  future  progress.  I  shall  concern  myself 
mainly  with  the  outlook  for  the  future,  if  for  no  other  reason  than  this, 
that  you  are  at  the  age  and  have  reached  the  point  in  your  career  at 
which  the  future  is  of  more  absorbing  interest  than  the  past.  It  is 
needless  to  say  that  in  my  reading  of  the  skies  I  make  no  particular 

*  Address  delivered  at  the  commencement  exercises  of  the  Medical  Depart- 
ment of  the  University  of  St.  Louis,  May,  1907. 
23  337 


338  MEDICAL   BESEABCH   AND    EDUCATION 

pretense  to  be  weather-wise  above  my  fellows.  Any  man  who  has  been 
identified  with  medical  research  and  education  for  fifteen  or  twenty 
years,  nay  for  a  much  shorter  time  than  that,  if  he  has  had  his  eyes  open, 
must  have  remarked  certain  tendencies,  a  certain  trend  in  our  progress. 
To  note  those  tendencies,  to  heed  the  straws  which  show  how  the  wind 
blows,  to  mark  the  set  of  the  tide,  does  not  need  uncommon  sharpness 
of  vision.    That  is  the  extent  of  my  soothsaying. 

I  desire  then  to  consider,  so  far  as  such  a  vast  theme  may  come  within 
the  time  at  my  disposal  here,  the  outlook  in  medicine,  with  what  inci- 
dental retrospective  glance  the  subject  may  invite.  I  propose  to  con- 
sider the  subject  under  two  heads:  the  outlook  in  medical  education — 
the  outlook  in  medical  investigation.  I  shall  not  trouble  you  with 
details.  I  could  have  informed  myself  first,  and  then  you,  how  many 
medical  schools  in  the  country  have  bacteriology  in  the  first,  and  how 
many  in  the  second  year;  how  many  colleges  give  more  than  60  hours 
to  the  teaching  of  practical  physiology  and  so  on,  and  from  such  data 
I  might  have  been  able  to  deduce,  by  properly  juggling  my  statistics, 
the  practical  conclusion,  for  example,  that  51%  hours  is  the  ideal 
amount  of  time  for  obstetrics  in  a  well-balanced  medical  curriculum. 
I  do  not  say  that  such  enquiries  are  unimportant,  but  I  have  spent  too 
many  hours  on  them  elsewhere  to  be  willing  to  spend  minutes  on  them 
here.  In  any  case  it  is  the  broad  features  of  the  subject  which  attract 
me  and  on  which  it  will  probably  be  most  profitable  for  you  that  I 
should  dwell. 

I.     The  Outlook  in  Medical  Education 

When  I  began  the  study  of  medicine  twenty-four  years  ago  at  the 
University  of  Edinburgh,  the  old  system  of  teaching  by  lectures  (a  whole 
hundred  of  them  in  each  course)  was  in  full  swing.  In  physiology  the 
lectures  were  very  good  of  their  kind  and  well  illustrated  by  lecture- 
table  experiments,  although  considerable  imagination  had  often  to  be 
exercised  by  students  sitting  on  the  back  benches  of  a  room  containing 
four  hundred  men  in  order  to  picture  to  themselves,  for  instance,  the 
appearance  of  a  frog's  gastrocnemius  muscle  as  it  contracted.  Of  labo- 
ratory work  there  was  practically  none.  One  quantitative  estimation  by 
Fehling's  solution  of  the  sugar  in  a  specimen  of  urine,  half  an  hour's 
coquetry  with  a  laryngoscope,  and  an  equal  length  of  time  spent  with 
the  ophthalmoscope  in  wooing  the  optic  disk,  usuallj^,  alas,  in  vain,  com- 


THE    OUTLOOK   IN   MEDICINE  339 

prised  the  whole  of  m}'  practical  work  in  physiology,  so  far  as  I  can 
remember.  In  histology  we  had  a  very  fair  laboratory  course,  and  gross 
anatomy  was  well  taught  according  to  the  old  style.  Botany,  zoology 
and  chemistry,  with  some  anatomy,  occupied  the  whole  of  our  first  year. 
In  the  second  year  surgical  lectures  and  dressing  in  the  surgical  wards 
were  taken,  as  is  still,  for  some  inexplicable  reason,  the  case  in  the 
Scottish  universities.  You  can  imagine  the  grip  we  got  of  surgery,  with 
our  anatomy  not  half  learned,  pathology  untouched,  and  physiology,  in- 
cluding histology,  just  begun.  In  the  third  year  we  had  pathology 
lectures,  with  a  fair  course  of  pathological  histology  and  the  chance  of 
acquiring  such  knowledge  of  gross  pathology  as  we  could  pick  up  by 
sitting  on  the  benches  of  the  post-mortem  room.  Of  bacteriology  we 
got  not  even  the  smack.  A  couple  of  years  after  I  graduated  in  medicine 
I  attended  the  first  course  of  practical  bacteriology  ever  given  in  the 
medical  school  of  the  great  University  of  Cambridge.  It  was  mainly 
taken  by  men  of  considerable  seniority.  Such  fledglings  as  medical  stu- 
dents, were,  if  not  actually  warned  off,  at  least  but  little  in  evidence. 

In  materia  medica,  which  included  pharmacology,  we  had  lectures 
alone ;  the  so-called  practical  class  in  materia  medica,  which  was  volun- 
tary, although  the  fee  for  it  was  not,  as  I  well  recollect,  being,  to  say 
the  least,  of  very  doubtful  utility.  The  work  in  clinical  medicine  in  the 
wards  was  good,  as  it  had  been  ever  since  bedside  work  for  students, 
under  the  name  of  clinical  clerking,  had  been  introduced  by  Hughes 
Bennett,  one  of  the  physicians  to  the  Eoyal  Infirmary  and  professor  of 
the  Institutes  of  Medicine,  now  usually  called  physiology.  Our  fourth 
year  was  occupied  by  obstetrics,  a  hundred  formal  lectures  again.  You 
could  not  buy  goods  of  that  kind  at  that  particular  shop  in  smaller 
quantities.  Gynecology  was  as  yet  hardly  differentiated  as  regards  its 
subject  matter  from  general  surgery,  although  the  teaching  of  it  was 
included  under  obstetrics.  The  fourth-year  work  included  also  a  homeo- 
pathic dose  of  skin  diseases,  and  a  good  filling,  substantial  meal  of 
medical  jurisprudence,  washed  down  with  hygiene,  or,  as  they  called  it, 
public  health.  Vaccination  was  watched  at  a  dispensary.  No  student, 
to  my  knowledge,  ever  performed  the  little  operation  himself.  Of 
instruction  in  ophthalmology  or  diseases  of  the  nose,  ear  or  throat,  we 
had  none.  Nevertheless  for  the  time  I  doubt  whether  on  the  whole 
there  was  any  better  undergraduate  course  anywhere  in  the  country,  or 
for  that  matter  in  the  world,  as  regards  practical  ward  instruction  in 
clinical  medicine. 


340  MEDICAL   BESEABCH   AND   EDUCATION 

The  general  educational  requirements  for  admission  were  by  no 
means  high,  and  the  proportion  of  graduates  in  arts  or  science  among 
the  medical  students  was  insignificant.  These  details  may  be  of  some 
interest  to  American  students  because  the  early  medical  schools  in  this 
country,  such  as  the  Medical  Department  of  the  College  of  Philadelphia, 
established  in  1765,  and  the  Medical  Department  of  King's  College, 
New  York,  now  Columbia  University,  established  three  years  later,  were 
modeled  on  the  University  of  Edinburgh.  The  celebrated  Dr.  BenjamiL. 
Eush  was  professor  of  chemistry  at  the  former. 

Progress  has  been  made  since  the  time  to  which  I  refer  both  in  Great 
Britain  and  in  this  country,  but  particularly  here,  so  that  it  is  not  too 
much  to  say  that  the  best  of  our  American  medical  schools  are  fully 
abreast  of  the  best  in  Europe.  One  might  go  even  a  little  farther  than 
this,  perhaps,  without  straying  beyond  the  bounds  of  strict  truth,  but  I 
prefer  to  quote  on  this  point  the  words  of  an  eminent  medical  educator 
in  Great  Britain,  Professor  Schafer,  of  Edinburgh  University.  In  an 
address  at  the  opening  of  the  session  of  the  Medical  Department  of  the 
Yorkshire  College,  Leeds,  in  1903,  he  made  the  following  pronounce- 
ment: 

"It  is  certainly  not  a  little  remarkable  that  the  American  univer- 
sities when  placed  in  the  possession  of  adequate  endowments,  make  no 
attempt  to  increase  the  number  of  their  graduates  by  a  lowering  of 
standards,  .  .  .  but  aim  entirely  at  attracting  students  both  by  the 
thoroughness  and  efficiency  of  their  teaching  and  by  the  facilities  for 
postgraduate  study  and  research  which  they  offer  in  all  departments  of 
science  and  medicine.  The  natural  result  of  this  must  be  that  these 
universities  will  not  only  obtain  the  pick  of  the  American  students,  but 
will,  as  years  go  on,  attract  students  .  .  .  from  other  countries,  so  that 
eventually  the  center  of  gravity  of  medical  science  will  become  shifted 
westward.  This  must  certainly  be  the  result  of  the  development  of  the 
universities  in  the  States,  which  will  eventually  take  the  part  which  was 
played  by  the  universities  of  Italy  in  the  Eenascence  and  by  those  of 
Germany  in  more  recent  times  unless  by  the  munificence  of  the 
private  benefactor,  or  direct  and  adequate  endowment  by  the  state,  our' 
own  universities  are  placed  upon  a  footing  which  shall  render  it  pos- 
sible for  them  to  compete,  by  thoroughness  of  equipment  and  the 
adequate  provision  of  a  staff  qualified  in  the  highest  manner  for  both 
teaching  and  research,  with  those  which  are  now  by  virtue  of  the  pos- 


TEE    OUTLOOK   IN   MEDICINE  341 

session  of  these  requirements  outstripping  us  upon  the  other  side  of  the     '^ 
Atlantic." 

The  most  important  changes  of  the  near  future,  actually  accom- 
plished in  one  or  two  of  our  foremost  schools,  in  progress  in  others  and 
bound  to  come  in  all  that  hope  to  survive  in  the  struggle  for  existence 
are,  I  believe,  the  following : 

1.  The  influence  of  the  professional  medical  educator  should  pre- 
dominate over  that  of  the  amateur.  Medical  education  must  more  and 
more  be  considered  a  branch  of  pedagogics. 

2.  An  increase  must  be  made  in  the  general  educational  require- 
ments for  admission.  The  freshman  must  bring  more  knowledge  in  his 
head  and  perhaps  more  cunning  in  his  hands  to  the  medical  school. 
Above  all  he  must  bring  the  trained  brain  which  already  knows  to  a 
certain  extent  how  further  knowledge  may  be  most  easily  acquired. 
How  high  the  standard  should  be  raised  is  a  question  where  differences 
of  opinion  may  be  properly  entertained.  It  is  to  some  extent  a  local 
question.  Nothing  would  be  more  foolish  than  to  aim  at  a  uniform 
standard  all  over  a  country  as  extensive  as  this,  the  different  parts  of 
which  are  in  very  different  stages  of  development,  although  a  minimum 
might  well  be  established.  There  must,  however,  always  be,  as  regards 
this  question  of  entrance  requirements,  best  schools  and  second-best 
schools,  but  it  must  be  carefully  looked  to  that  the  second-best  schools 
are  good  enough. 

3.  A  more  general  insistence  on  a  sound  knowledge  of  physics, 
chemistry  (inorganic  and  organic)  and  general  biology  before  entrance, 
so  that  the  whole  of  the  four  years  may  be  devoted  to  strictly  medical 
work,  under  which  head  I  of  course  emphatically  include  anatomy, 
physiology  and  pathology. 

4.  The  introduction  of  the  laboratory  system  of  instruction  more 
extensively  and  more  intensively,  and  in  order  that  time  may  be  found 
for  this,  curtailment  of  the  number  of  lectures,  especially  in  subjects 
like  anatomy. 

5.  Most  important  of  all,  the  introduction  and  the  extension,  where 
already  introduced,  of  real  bedside  work  in  the  wards,  both  in  medicine 
and  in  surgery,  of  course  under  responsible  supervision.  The  work  in 
the  policlinic  or  dispensary  is  of  great  value,  but  can  not  take  the  place 
of  the  continuous  study  of  the  natural  history  of  disease  which  is  possible 
to  the  student  who  works  in  the  wards.    To  obtain  the  best  conditions 


342  MEDICAL   BESEABCE   AND   EDUCATION 

for  this  sort  of  work,  medical  schools  must  have  hospitals  attached  to 
them  and  under  their  complete  control.  It  seems  probable  that  one  of 
the  developments  of  the  future  in  medical  education  will  be  the  building 
and  endowment  of  such  hospitals.  Large  funds  will  be  required  for  this 
purpose  and  a  large  fund  of  patience  and  persistence  in  educating  the 
public  out  of  its  prejudices,  and  let  me  add  in  educating  our  rich  men 
or  our  legislatures  out  of  some  of  their  money. 

6.  To  aid  in  effecting  a  synthesis  between  the  scientific  and  the 
clinical  work  special  chairs  may  be  established,  such  as  the  chair  of 
experimental  medicine  recently  endowed  at  Cleveland.  The  foundation 
of  such  chairs,  it  is  scarcely  necessary  to  say,  far  from  obviating 
the  necessity  of  the  development  of  a  more  scientific  type  of  clinical 
investigator  and  teacher,  will  in  fact  emphasize  that  necessity. 

7.  The  establishment  of  laboratories  of  public  hygiene  and  preven- 
tive medicine  and  provision  for  the  training  of  medical  officers  of  health. 
This  country  must  follow  Europe  in  national,  state  and  municipal 
hygiene.  In  the  crowded  countries  of  the  old  world  the  majority  of  the 
population  already  lives  in  cities.  It  is  of  vital  importance  that  the  con- 
ditions under  which  they  work  and  the  environment  in  which  they  live 
should  be  made  as  healthy  as  possible.  This  is  a  problem  which  is  not 
jet  as  acute  in  this  country  with  its  immense  roiral  areas,  but  it  is  by 
mo  means  remote  and  it  is  forcing  itself  more  and  more  into  the  fore- 
ground each  year.  Let  me  repeat  one  of  the  prime  necessities  of  the 
near  future  here  in  America  (I  said  "the  near  future,"  but  the  problem 
is  with  us  now)  is  the  provision  of  an  efficient  and  well-paid  body  of 
medical  officers  of  health,  who  after  acquiring  some  experience  in  prac- 
tise shall  adopt  public  hygiene  as  a  life  profession.  Undoubtedly  the 
present  system  of  precarious  political  appointments  can  not  last. 

II.     The  Outlook  in  Medical  Investigation 

When  I  began  the  study  of  medicine  antiseptic  (and  aseptic)  sur- 
gery, or  at  least  that  modern  and  thoroughgoing  development  of  it 
initiated  by  Lister,  was  little  more  than  fifteen  years  old.  It  was  scarcely 
yet  universally  accepted  even  in  Edinburgh  (with  Glasgow),  the  cradle 
of  Listerism,  where  Lister  was  himself  for  a  time  professor  of  clinical  sur- 
gery. Old  Professor  Spence,  who  filled  the  chair  of  surgery  while  I  was 
still  a  student  of  arts,  never  to  his  dying  day  convinced  himself  that  there 
was  very  much  in  the  new  method  of  treating  wounds.    For  years  after 


TEE    OUTLOOK  IN   MEDICINE  343 

I  started  my  course  it  was  antiseptic  rather  than  asej)tic  procedures 
which  were  relied  on.  Crude  and  cumbrous  too  were  the  methods  by 
which  the  surgeons  endeavored  to  free  the  wounds  and  keep  them  free 
from  germs.  The  air  was  pungent  with  the  carbolic-acid  spray.  The 
kettles,  atomizers  you  would  call  them,  sizzled  and  fizzed;  nurses, 
assistants  and  operator  worked  in  a  cloud  of  spray  which  was  by  no 
means  agreeable  to  nose  and  eyes.  WTien  wounds  were  being  dressed 
in  the  wards  a  miniature  steam  engine  accompanied  the  surgeon  on  his 
rounds.  With  all  precautions  suppuration  was  common,  although  of 
course  far  less  so  than  before  the  days  of  Lister.  Slips  of  technique 
which  would  now  be  considered  unpardonable  in  an  interne  were  com- 
mitted daily  in  that  great  hospital  by  men  of  international  reputation. 
One  of  the  surgeons  to  the  infirmary,  a  professor  in  a  university,  a 
man  in  the  prime  of  life,  by  no  means  fossilized  in  his  ways,  one  would 
say,  habitually  operated  in  an  old  frock  coat,  which  apparently  was  kept 
in  the  hospital  for  the  purpose,  and  did  not  seem  ever  to  have  been 
cleaned.  I  remember  well  that  when  he  turned  up  the  sleeves,  as  he 
always  did  before  he  began  to  operate,  old  blood  stains  were  all  too 
visible  on  the  lining.  He  was  a  surgeon  of  considerable  repute;  the 
operating  theater  was  filled  with  students  from  all  quarters  of  the 
world,  for  Edinburgh  at  that  time  was  perhaps  the  most  cosmopolitan 
of  all  the  great  medical  centers  and  on  it  converged  a  crowd  of  students 
of  all  colors  and  nationalities,  especially,  of  course,  representing  every 
part  of  the  British  Empire.  All  this  was  sixteen  or  seventeen  years 
after  Lister  published  his  epoch-making  paper  on  "A  New  Method  of 
Treating  Compound  Fractures,  Abscess,  etc."  In  that  paper  he  refers  as 
the  foundation  of  his  new  method  to  the  experiments  of  Pasteur  on  the 
bacterial  origin  of  putrefaction. 

I  need  not  dwell  upon  the  immense  impetus  which  the  firm  estab- 
lishment of  aseptic  and  antiseptic  methods  imparted  to  surgery  in  all 
its  branches.  Obstetrical  practise  was  scarcely  less  affected.  Since  my 
time  (if  you  please  I  do  not  consider  myself  an  old  man)  a  generation 
of  practitioners  has  grown  up  which  accepts  the  Listerian  methods  as 
axiomatic.  They  have  been  so  drilled  and  disciplined  in  surgical 
cleanliness  that  it  has  become  to  them  a  second  nature.  I  suppose  it 
would  be  physically  impossible  for  any  one  of  you  young  gentlemen  to 
perform  a  surgical  operation  in  an  old  frock  coat. 

Let  me  revert  for  a  moment  to  the  fact  that  when  I  was  a  student 


344  MEDICAL   BESEAPvCE   AND   EDUCATION 

bacteriology  was  still  a  novelty,  considered  by  many  to  have  little 
practical  value.  It  is  true  that  it  was  beginning  to  excite  interest 
among  the  more  alert  and  open-minded,  and  particularly  among  the 
younger  members  of  the  profession,  but  it  was  considered  quite  outside 
the  ordinary  medical  curriculum.  It  was  just  the  year  before  I  first 
matriculated  as  a  medical  student  that  Koch  published  his  discovery 
of  the  tubercle  bacillus,  a  discovery  which  has  revolutionized  our  ideas 
of  the  causation  of  tuberculosis,  has  placed  in  our  hands  the  means  of 
greatly  limiting  its  spread,  and  eventually,  we  can  hardly  doubt,  the 
means  of  eradicating  it  from  the  world. 

Malaria  was  still  the  mysterious  scourge  it  had  ever  been.  The 
proof  of  its  transmission  by  mosquitoes  has  given  a  great  impulse  to 
tropical  hygiene  and  bids  fair  in  the  future  to  render  habitable  and 
healthy  some  of  the  most  beautiful  and  fertile  regions  of  the  earth  now 
deadly  to  white  men.  The  discovery  by  an  illustrious  American,  Major 
Reed,  that  yellow  fever  is  propagated  in  a  similar  way  has  done  much  to 
rob  that  pest  of  the  Antilles  of  its  terrors.  Incidentally  it  has  greatly 
facilitated  the  construction  of  the  Panama  Canal. 

I  need  scarcely  say  that  the  treatment  of  diphtheria  by  antitoxin  was 
undreamed  of  at  the  time  to  which  I  refer.  Tracheotomy  as  a  last 
desperate  device  when  suffocation  was  threatened  was  the  best  resource 
of  our  art. 

In  the  study  of  the  internal  secretions,  a  study  which  has  now 
assumed  such  practical  importance,  a  beginning  had  been  made  in  the 
elucidation  of  the  relations,  of  the  thyroid  to  the  economy.  But  nothing 
was  as  yet  known  of  the  fundamental  role  played  by  the  pancreas  in 
carbohydrate  metabolism,  and  nothing  of  the  secretion  of  the  pressor 
substance  epinephrin  (adrenalin)  by  the  suprarenal  gland.  The  physi- 
ology of  the  pituitary  was  also  a  terra  incognita.  While  much  still  re- 
mains to  be  known  of  the  function  of  the  hypophysis,  its  exploration  has 
now  hopefully  begun. 

For  the  future  it  seems  clear  that  important  discoveries  in  the  etiology 
and  treatment  of  various  bacterial  diseases  are  still  to  be  anticipated. 
Pneumonia,  which  now  runs  its  course  without  check  by  medicine,  will, 
it  may  be  confidently  hoped,  be  curbed.  Malignant  growths,  of  whose 
very  causation  we  are  in  perfect  ignorance,  will,  we  may  well  believe,  in 
time,  yield  up  their  secret  and  become  tractable  to  some  surer  and  less 
terrible  therapy  than  that  of  the  knife.     Eecent  work  on  the  suturing 


TEE    OUTLOOK  IN   MEDICINE  345 

of  blood  vessels  and  the  transplantation  of  organs  may  possibly  enable 
us  in  the  future  to  substitute  in  some  cases  a  healthy  for  an  injured  or 
diseased  part.  A  great  extension  of  the  field  of  nerve  surgery  may 
enable  relief  to  be  afforded  in  hitherto  incurable  affections  of  the 
nervous  system. 

It  is  to  be  expected  that  medicine,  including  surgery  or  mechanical 
medicine,  will  depend  for  its  progress  more  and  more  on  experimental 
work  in  the  laboratory,  and  probably  it  will  be  found  expedient  for 
research  as  well  as  for  teaching,  and  indeed  still  more  for  research,  to 
erect  separate  foundations  to  fill  the  gap  between  the  laboratory  and  the 
clinical  work. 

Organization'  and  Endowment  of  Eesearch 

A  few  words  more  may  be  permitted  to  emphasize  again  the  necessity 
of  great  endowments  for  the  future  development  of  medical  research  both 
for  laboratories  and  for  hospitals.  This  is  a  matter  which  is  not 
thoroughly  understood  by  the  general  public,  by  our  moneyed  men,  or 
by  our  legislators.  Everybody  knows  that  for  ordinary  material  benefits 
humanity  has  to  pay  in  labor  and  in  money.  We  are  digging  a  canal 
down  there  at  Panama.  Suppose  somebody  said,  "  Nature  obviously  in- 
tended a  canal  to  be  dug  there.  It  is  bound  to  come.  It  is  only  a 
question  of  time.  Sooner  or  later  we  shall  have  the  canal,  anyway,  and 
there  is  no  use  making  any  special  effort  about  it.  "We  can  not  much 
hasten  or  hinder  it."  Would  you  not  all  recognize  that  he  was  speaking 
nonsense?  But  when  we  read  in  the  daily  press  of  the  wonderful 
triumphs  of  medicine,  how  malaria  or  yellow  fever  or  diphtheria  has 
been  conquered  and  shorn  of  its  terror,  we  are  led  to  believe  that  apart 
altogether  from  human  effort,  or  at  least  apart  from  organized  effort, 
apart,  above  all,  from  the  expenditure  of  hard  cash,  we  shall  some  time  or 
other  gain  the  mastery  over  cancer  and  pneumonia  and  all  the  other 
diseases  that  have  hitherto  been  our  masters.  We  sit  down  and  con- 
gratulate ourselves  that,  much  having  already  been  done  in  the  way  of 
medical  discovery,  much  more  will  surely  be  done,  but  too  often  with 
the  tacit  assumption  that  it  is  none  of  our  business,  and  that  all  we  have 
to  do  is  to  read  in  our  morning  papers  of  those  wonderful  achieve- 
ments after  they  have  been  accomplished.  But  is  that  the  way  you  do 
about  the  canal  ?  No !  The  matter  is  agitated  in  the  press  and  in  the 
country.    It  is  discussed  in  congress.     Surveys  are  made,  rival  routes 


846  MEDICAL   BESEAECH   AND   EDUCATION 

considered,  estimates  prepared,  and  when  the  whole  matter  has  been 
thoroughly  threshed  out,  the  government  of  this  great  country  under- 
takes the  work,  primarily  in  the  interests  of  the  United  States,  but 
incidentally  for  the  benefit  of  all  mankind.  The  president  goes  to  the 
Isthmus  to  give  to  the  work  the  imprimatur  and  the  impetus  of  his 
presence,  and  you  pour  your  treasure  and  your  energy  into  the  under- 
taking till  you  have  opened  a  path  for  the  commerce  of  the  orient  to 
New  Orleans  and  N"ew  York.  But  this  you  say  is  a  work  of  national 
and  international  importance.  And  the  cure,  or  prevention,  or  extir- 
pation of  tuberculosis  and  pneumonia — what  kind  of  a  work  is  that  ? 

Nobody  expects  that  a  Panama  Canal  will  be  dug  by  the  chance 
efforts  of  philanthropic  engineers  and  philanthropic  laborers  who  for 
love  of  their  work,  for  love  of  their  kind,  or  for  love  of  fame  will  from 
time  to  time,  as  the  spirit  moves  them,  devote  themselves  to  that  great 
undertaking.  No !  Such  works  are  accomplished  either  by  private  cor- 
porations possessed  of  great  resources  who  expect  to  reap  rich  profits 
from  their  enterprise  and  by  their  paid  employees  hired  at  a  wage 
fixed  in  the  ordinary  way  by  the  haggling  of  the  market,  or  they  are 
accomplished  at  the  public  cost  and  for  the  public  benefit.  It  is  one  of 
the  glories  of  science,  and  of  medical  science  as  much  as  any,  that  in 
all  ages  men  have  been  willing  to  sacrifice  their  material  interests,  and 
the  interests  of  those  dear  to  them,  to  fill  their  hours  with  unpaid  toil 
of  the  hand  and  of  the  brain  in  the  hope  of  enlarging  the  boundaries  of 
knowledge.  In  the  face  of  neglect,  of  opposition,  sometimes  of  actual 
persecution  they  have  continued  their  noble  work,  and  the  world  which 
was  not  worthy  of  them,  which  ignored  or  laughed  at  their  labors,  has 
made  no  scruple  of  profiting  by  their  discoveries.  Even  in  our  day, 
when  such  matters  are  coming  to  be  better  understood,  there  are  still 
many  who  seem  to  think  that  in  science  discoveries  are  made  by  chance, 
the  wind  blowing  where  it  listeth,  men  dreaming  new  things  in  their 
sleep,  and  that  it  makes  little  difference  in  the  output  whether  research 
is  encouraged  and  sustained  by  the  fostering  care  of  governments  or 
private  benefactors  or  whether  it  languishes  in  neglect.  I  believe  that 
in  the  future  clearer  ideas  will  prevail  in  regard  to  this  matter  and  that 
it  will  be  perceived  more  generally  in  this  country,  as  it  is  to  some  extent 
already,  and  as  it  has  long  been  in  Germany,  that  in  science  as  in 
everything  else,  upon  the  whole  the  world  will  get  what  it  pays  for. 
Take  any  one  of  the  burning  practical  problems  of  medicine,  some  of 


TEE    OUTLOOK  IN   MEDICINE  347 

which  I  have  already  alluded  to  and  which  I  make  no  apology  for 
repeating,  the  causation  and  the  prevention  or  cure  of  malignant  disease, 
of  pneumonia,  of  scarlet  fever,  of  arterio-sclerosis,  of  nephritis,  of 
diabetes  mellitus  or  what  not.  "^Tiat  do  we  know  about  them,  and  how 
are  we  going  to  increase  our  knowledge?  Does  anybody  doubt  that 
when  we  know  more  we  shall  be  able  to  do  more,  to  control,  to  palliate 
or  to  cure,  to  prevent  or  perhaps  to  eradicate  some  of  these  diseases,  to 
limit  the  toll  of  human  life  which  they  take  year  in  and  year  out  ? 

How  soon  we  shall  be  able  to  do  this  depends  in  all  probability  upon 
the  amount  of  well-organized,  well-directed  investigation  concentrated 
upon  them.  The  greater  our  efforts  the  sooner  shall  we  be  rewarded 
with  results.  And  the  larger  the  amount  of  money  appropriated  for 
these  purposes,  other  things  being  equal,  the  speedier  and  the  surer  will 
be  the  harvest  from  the  efforts  of  workers  already  enlisted,  and  from 
those  of  new  workers  drawn  into  such  investigations  from  other  fields. 
This  night  in  the  city  of  St.  Louis  children  are  sickening  and  dying, 
men  and  women  are  being  cut  off  in  the  prime  of  life,  and  ill  health  is 
embittering  and  sterilizing  the  lives  of  thousands  even  where  it  is  not 
curtailing  them,  all  because  we  do  not  know  enough.  It  is  as  sure  as 
anything  can  be,  I  believe,  that  the  wise  expenditure  of  money  in  suffi- 
cient amount  in  the  last  fifty,  it  may  be  in  the  last  ten  years,  perhaps 
even  in  the  last  year  or  last  month,  would  already  have  placed  in  the 
hands  of  the  profession  effective  means  of  preventing  some  of  the  deaths 
which  will  take  place  this  night  in  your  city,  perhaps  among  the 
acquaintances,  it  may  be  among  the  friends  of  some  of  this  great  audi- 
ence. I  wonder  if  there  is  any  rich  philanthropist,  or  any  present  or 
prospective  legislator  (or  his  wife  or  his  sweetheart)  within  reach  of 
my  voice.  If  so  I  want  to  reason  with  such,  lest  perchance  some  feeble 
word  of  mine  (insignificant  causes  do  sometimes  produce  great  events) 
might  as  an  arrow  from  a  bow  shot  at  a  venture  strike  the  mark.  Yes, 
it  is  true,  I  say,  people  are  dying  now  whom  medicine  or  surgery  might 
save  had  some  rich  man  seen  his  privilege,  or  the  state  its  duty  in  the 
past,  perhaps  in  the  past  year.  People  are  dying  now  because  scientific 
investigation  has  been  starved  and  discouraged  by  unwise  parsimony  or 
sheer  indifference  on  the  part  of  those  who  had  the  power  to  aid.  Talent 
has  been  spending  itself  in  less  important  fields  which  might  have  been 
attracted  into  this  high  career.  Consider  what  the  state  does  in  other 
relations.    It  fosters  agriculture,  it  fosters  commerce,  it  often  gi-inds  its 


348  MEDICAL   BESEABCE   AND    EDUCATION 

people  to  the  dust  by  costly  preparations  for  war  as  the  alleged  safeguard 
of  peace.  I  am  not  quarreling  with  these  things,  not  even  with  the  costly 
preparations  for  war.  On  the  contrary,  in  certain  circumstances  we  must 
all  applaud  them.  But  has  the  state  then  no  duties  to  perform  in  the  war 
on  disease?  I  am  going  to  make  a  suggestion  which  I  suppose  is  an 
exceedingly  foolish  one.  We  know  that  shortly  a  Congress  of  the  Na- 
tions is  to  assemble  at  The  Hague  to  consider  various  questions  of  inter- 
national law  and  international  relations.  Several  of  the  countries  repre- 
sented desire  to  bring  the  question  of  the  limitation  of  armaments 
before  that  august  tribunal.  England  wishes  them  all  to  go  more 
slowly  in  the  building  of  battleships.  A  modern  battleship  costs  at  least 
six  to  eight  millions  of  dollars,  and  as  things  are  going  at  present  is  fit 
for  the  scrap  heap  in  ten  or  twelve  years.  No,  I  am  not  going  to  trot 
out  once  more  the  idea  cherished  by  many  noble  hearts  and  apparently 
entertained  even  by  such  hard  heads  as  that  of  Mr.  Andrew  Carnegie, 
that  we  can  by  calling  war  wicked,  wasteful  and  absurd  decree  that  the 
millennium  shall  begin  next  Monday  morning.  The  abolition  of  war 
and  warlike  armaments  is  not  practical  politics  for  our  generation  or 
our  century.  My  suggestion  is  something  much  more  modest.  What 
a  magnificent  endowment  for  research  in  medicine  the  price  of  a  sijigle 
battleship  would  be !  Suppose  now  that  at  The  Hague  each  of  the 
great  naval  powers  were  to  agree  to  forego  the  building  of  one  solitary 
battleship  and  to  piit  the  money  into  laboratories  and  hospitals,  pri- 
marily for  medical  research,  incidentally,  and  none  the  less  beneficent 
need  this  secondary  use  be,  for  the  diagnosis  and  treatment  of  disease. 
Or  lest  the  audacity  of  such  a  suggestion  should  startle  the  world  of 
statesmen  and  diplomatists  (they  of  course  are  always  listening  to  hear 
what  may  be  said  in  St.  Louis  even  by  the  most  insignificant  individual) 
let  us  not  claim  the  price  of  a  battleship  from  each  power  in  perpetuity, 
but  only  the  interest  on  it  for  a  term  of  years,  or  until  such  a  time  as 
some  definite  object,  such  as  a  knowledge  of  the  etiology  of  cancer  and 
the  development  of  an  effective  curative  procedure  for  it  were  accom- 
plished, the  principal  sum  then  to  revert  to  its  original  purpose  if  the 
nations  concerned  still  felt  that  they  positively  could  not  get  along 
without  those  particular  battleships.  The  capital  sum  would  still  be 
intact  and  they  could  throw  it  into  the  sea  with  the  other  vast  sums 
which  have  been  squandered  on  that  particular  result  of  human  folly, 
pride  or  panic. 


THE    OUTLOOK   IN   MEDICINE  349 

And  now  one  more  personal  word.  I  sincerely  congratulate  yon  who 
have  entered  to-day  into  the  ranks  of  our  noble  science  and  craft.  If  I 
have  read  the  future  aright  the  sky  of  medicine  is  bright  with  promise. 
Never  was  our  science  so  interesting,  our  knowledge  so  varied  and  so 
rich,  our  art  so  capable  of  good  to  individual  men  and  so  closely  inter- 
woven with  the  common  life  of  cities  and  nations.  Never  did  the  doctor 
occupy  so  high  a  position  in  the  estimation  of  mankind,  or  deserve  to 
do  so.  I  have  cast  my  eye  back  over  a  period  of  more  than  twenty  years 
and  noted  our  progress  in  that  time  and  speculated  upon  the  triumphs 
still  to  be  won.  Should  one  of  you  twenty  years  from  now,  on  some  such 
occasion  as  the  present,  indulge  his  fancy  and  consult  his  memory  in 
taking  stock  of  the  position  and  prospects  of  medicine  at  that  date, 
he  may  chronicle  a  record  of  achievement  beside  which  the  boasted 
triumphs  of  the  past  two  decades  may  sink  into  insignificance.  But  if 
this  should  be  the  case,  depend  upon  it  these  blessings  and  these  tri- 
umphs will  never  be  obtained  "  on  the  cheap."  The  future  victories  of 
medicine  will  not  be  won  by  the  bare  and  unarmed  hands  of  the  solitary 
enthusiast,  but  by  drilled  and  armed  battalions.  They  will  come  as  the 
result  of  the  strenuous  and  sustained  and  well-directed  efforts  of  numer- 
ous trained  investigators  working  on  an  adequate  scale,  with  adequate 
resources  at  their  disposal. 

Money  can  not  buy  great  discoveries  nor  the  genius  by  which  they 
are  made.  But  it  can  buy  the  resources  and  opportunities  for  lack  of 
which  genius  is  too  often  hampered  in  its  work,  and  it  can  attract  to 
science  from  less  important  spheres  talent  which  may  be  wasting  itself 
in  lower  forms  of  effort.  Let  then  our  legislators  ponder  it,  let  our 
millionaires  take  note,  money  properly  applied  will  bring  results  in 
medical  science  as  it  will  in  agriculture,  in  industry  and  in  com- 
merce, fabulous  results  it  may  be,  astounding  percentages  of  blessing 
and  healing  for  the  nations. 


PEOBLEMS,  METHODS  AND  ORGANIZATION"  OF  RESEAECH, 
WITH   SPECIAL  EEFEEEKCE  TO   PHYSIOLOGY^ 

By  G.  N.  Stewart,  A.M.,  M.D.,  Sc.D.,  D.P.H., 

Professor  of  Experimental  Medicine  and  Director  of  the  Gushing 
Laboratory,  Western  Eeserve  University 

When  Dr.  Barker  did  me  the  honor  to  invite  me  to  address  you  this 
evening  he  suggested  that  a  physiological  subject  of  a  general  nature 
rather  than  a  detailed  discussion  of  a  particular  research  would  be 
most  appropriate.  He  indicated  further  that  as  far  as  possible  the 
subject  should  be  treated  without  the  use  of  technical  phraseology. 
I  shall  endeavor  to  meet  his  wishes  by  considering  in  a  perfectly  gen- 
eral way  and  without  any  care  for  formal  completeness  some  of  the 
main  problems  with  which  our  science  is  at  present  busied,  or  will  in 
all  probability  be  busied  in  the  immediate  future.  In  doing  so  I  shall 
mention  without  going  into  detail  some  of  the  methods  which  seem  to 
afford  the  greatest  promise  of  success  in  attempting  to  solve  these 
problems.  I  hope  there  is  somebody  here  who  knows  less  about  this  sub- 
ject than  I  do.  If  so,  I  wish  to  be  understood  by  those  who  know  more, 
and  I  am  quite  aware  that  several  of  my  audience  must  be  included  in 
this  category,  to  be  directing  my  remarks  entirely  to  him.  If  I  am  the 
most  ignorant  man  among  us  in  regard  to  this  particular  theme,  and 
since  I  began  turning  it  over  in  my  mind,  I  am  quite  prepared  to  admit 
anything  you  like  about  it,  will  you  be  kind  enough  to  consider  that 
what  I  seem  to  address  to  you  is  in  reality  a  soliloquy.  But  revenons  a 
nos  moutons. 

The  General  Problem  of  Physiologij. — In  a  sense  we  may  say  that 
physiology  has  but  one  problem,  the  description,  interpretation,  explana- 
tion of  all  the  peculiar  phenomena  which  we  associate  with  living 
matter.  I  shall  not  discuss  the  meaning  of  the  terms,  "  interpretation," 
"explanation,"  when  used  in  this  sense,  nor  shall  I  inquire  whether 
when  we  "  explain  "  the  occurrence  of  a  given  phenomenon,  for  example 
when  we  explain  the  swelling  of  the  colored  blood  corpuscles  in  a 

^Address  before  the  Biological  Society  and  the  Medical  Club  of  the  Uni- 
versity of  Chicago,  January,  1903. 

350 


BESEABCH   PROBLEMS  351 

hypotonic  solution  (i.  e.,  in  a  solution  containing  a  smaller  number  of 
molecules  in  the  liter  than  the  blood  serum)  as  due  to  the  lowering  of 
the  osmotic  pressure  of  the  liquid  in  which  they  are  suspended,  we  in 
reality  advance  beyond  the  description  of  the  "  how ''  to  the  explanation 
of  the  "  why."  I  shall  decline  also  to  entangle  myself  in  the  discussion 
of  the  question  what  we  mean  when  we  speak  of  one  phenomenon  being 
the  cause  of  another.  These  inquiries  form  a  portion  of  the  subject 
matter  of  philosophy  and  metaphysics.  Some  of  the  keenest  intellects 
that  have  ever  been  vouchsafed  to  the  sons  of  men  have  spent  themselves 
upon  them,  generation  after  generation,  with  results  or  without  results, 
according  to  the  standpoint  from  which  you  judge  their  labors. 
Assuredly  these  questions  are  not  without  interest,  ay  and  fundamental 
interest,  for  all  investigators  of  natural  phenomena.  But  it  will  be 
sufficient  for  our  purpose  if  we  consider  that  a  phenomenon  is  explained 
when  we  have  completely  unfolded  its  relations  to  the  other  phenomena 
which  in  the  observed  orderly  sequence  of  nature  always  precede  it,  and 
the  causes  of  which  are  known,  and  that  the  causes  of  a  phenomenon  are 
known  when  stage  by  stage  we  can  deduce  the  occurrence  of  this  partic- 
ular phenomenon  from  the  state  of  things  which  we  consider  ultimate 
or  beyond  further  analysis.  For  example,  in  the  present  condition  of 
our  knowledge  of  physics  and  cosmology,  the  general  problem  of 
physiology  might  be  considered  completely  solved  if,  given  the  nature, 
number,  distribution,  mass  and  movements  of  the  elementary  particles 
(molecules,  atoms  and  electrons)  of  all  kinds  of  living  matter  at  any 
particular  moment,  and  the  nature,  number,  distribution,  mass  and 
movements  of  the  elementary  particles  of  all  the  unorganized  matter 
acting  on  the  living  matter,  we  could  from  mechanical  considerations 
deduce  the  whole  cycle  of  changes  occurring  in  the  life  career  of  all  the 
particular  kinds  of  living  matter.  Here  the  problem  of  the  origin  of 
life  is  not  supposed  to  be  included  in  the  scope  of  physiology,  and  it  is 
assumed  that  no  other  forces  are  concerned  in  the  phenomena  of  life 
than  the  forces  of  the  inorganic  world.  But  if  we  adopt  the  hypothesis 
that  living  matter  was  originally  developed  from  dead  matter  on  the 
surface  of  the  earth  (an  alternative  hypothesis,  as  you  are  aware,  is  that 
of  Lord  Kelvin,  who  suggests  that  the  primal  germ  might  have  been 
carried  from  some  extra-terrestrial  region  by  a  meteorite)  a  complete 
solution  of  the  general  problem  of  physiology  would  include  the  explana- 
tion of  this  development.     Again  if  we  adopt  the  vitalistic  hypothesis 


352  MEDICAL   BESEAJRCH   AND   EDUCATION 

in  the  only  sense  in  which  as  I  conceive  it  can  be  held  by  a  modern 
physiologist,  the  general  problem  of  physiology  would  be  to  determine 
in  how  far  the  phenomena  of  living  matter  are  the  outcome  of  the  forces 
with  which  we  are  familiar  in  unorganized  matter,  in  how  far  they  are 
due  to  a  special  "vital  force"  acting  of  course  in  conjunction  with 
"  ordinary "  physical  and  chemical  forces,  and  what  the  nature,  mani- 
festations, and  possible  transformations  of  this  vital  force  are.  And  let 
me  take  the  opportunity  to  remark  that  there  is  nothing  necessarily 
absurd  in  the  idea  of  a  peculiar  form  of  energy  pervading  all  living 
matter.  The  chances  at  present  seem  to  be  in  favor  of  the  ultimate 
explanation  of  life  on  mechanical  lines.  But  while  the  phantom  of 
vitalism  must  never  be  permitted  to  divert  us  from  pushing  our  physical 
and  chemical  researches  to  the  utmost,  the  philosophical  inquirer  will 
scarcely  care  to  assert,  at  the  present  stage  of  our  progress,  that  it  is 
impossible  that  a  peculiar  vital  force  should  exist. 

I  have  purposely  displayed  the  general  physiological  problem  before 
you  in  all  its  breadth,  in  all  the  vastness  of  its  scope,  in  order  to  impress 
upon  you  the  fact  that  its  solution  is  only  practicable,  if  at  all,  by  the 
successive  attack  of  much  more  limited  and  special  questions.  The 
"  vaulting  ambition  "  which  will  not  deign  to  occupy  itself  with  any  but 
the  most  general  problems  and  neglects  the  cultivation  of  the  narrow 
though  fruitful  fields  of  special  research,  is  extremely  likely  to  "  o'erleap 
itself  and  fall  on  the  other  side,"  and  while  certainly  more  respectable 
than  the  prejudice  which  refuses  to  recognize  the  wider  aspects  of  physi- 
ology at  all,  has  perhaps  been  not  less  a  hindrance  to  physiological 
progress.  At  the  same  time  let  me  say,  and  say  it  emphatically,  that 
the  man  who  has  no  clear  idea  of  the  goal,  the  grand  denoument,  so  to 
speak,  to  which  all  physiological  research  should  tend,  will  fail  to  make 
the  most  even  of  his  special  experiments  by  failing  to  fit  them  into  the 
fabric  of  which  they  should  form  a  part,  just  as  if  a  builder  working 
without  a  plan  were  to  waste  a  world  of  toil  in  the  hewing  and  chiseling 
of  stones  that  he  is  never  to  use,  or  which  when  built  into  the  wall  were 
out  of  proportion  or  out  of  plumb.  There  is  very  real  danger  that  when 
one  does  not  take  a  broad  view  of  the  aims  and  a  broad  outlook  over  the 
field  of  physiological  research,  he  will  fail  to  see  the  connection  of  the 
fact  which  he  discusses  with  other  facts,  and  a  collection  of  isolated  and 
unclassified  facts  is  no  more  a  science  than  a  heap  of  stones  is  a  house. 
As  Claude  Bernard  said  even  in  his  time,  "Physiology  is  the  funda- 


BESEABCH    PROBLEMS  353 

mental  part  of  medicine,  Xevertheless,  the  physiological  facts  dis- 
covered in  the  laboratories  are  becoming  so  numerous  that  they  threaten 
to  encumber  medical  science  and  to  obscure  it,  if  one  does  not  investi- 
gate the  laws  which  relate  them  to  clinical  facts,  and  thus  trace  the  first 
lines  of  experimental  medicine." 

In  a  word,  unity  must  be  given  special  research  by  keeping  the  gen- 
eral problem  in  view.  Fortunately  it  is  not  difficult  to  do  this,  for  if  we 
conduct  our  special  inquiries  in  a  proper  way,  we  shall  find  that  when 
followed  into  all  their  consequences,  they  inevitably  conduct  us  at  last 
to  the  general  problem  of  the  nature  of  living  matter. 

Let  me  illustrate  this  point  by  one  or  two  perfectly  familiar  exam- 
ples. The  discovery  of  the  circulation  of  the  blood  by  Harvey  was 
assuredly  a  most  important,  and  has  usually  been  considered  a  most 
fundamental,  contribution  to  physiology.  It  blew  to  the  winds  a  multi- 
tude of  vague  fancies  and  vitalistic  conceptions,  and  so  illuminated 
this  great  function  that  down  to  this  very  hour  every  lecturer  on 
physiology  describes  the  circulation  essentially  as  Harvey  described  it, 
as  a  circulation  carried  on  on  ordinary  hydraulic  principles  through  the 
action  of  a  central  pump,  the  heart.  Yet  the  solution  of  Harvey's 
problem,  fundamental  though  it  seems,  immediately  presents  us  with 
another,  much  more  subtle,  much  more  elusive,  viz,,  what  it  is  that 
happens  in  the  tissue  of  the  heart  which  causes  it  to  beat.  As  you  are 
aware,  that  is  a  problem  which  is  at  this  very  moment  engaging  the 
most  active  attention.  In  order  to  attempt  its  solution  with  a  prospect 
of  success,  physiologists  have  felt  constrained  to  subdivide  it,  and  to  ask 
first  of  all  whether  the  cause  of  the  rhythmical  beat  of  the  heart  resides 
in  the  nervous  structures  or  in  the  muscular  fibers  of  the  cardiac  wall. 
I  need  not  go  into  the  history  of  the  discussion  which  has  arisen  over 
this  question.  For  a  quarter  of  a  century  or  more  numerous  workers 
have  labored  at  the  task,  I  do  not  wish  to  seem  to  prejudge  a  question 
which  is  still  pending.  But  it  seems  probable  that  the  outcome  of  the 
controversy  will  be  to  establish  the  cause  of  the  automatic  beat  in 
the  muscular  fibers  of  the  heart.  Here  again,  however,  there  is  no 
finality.  The  question  immediately  arises,  and  a  far  more  funda- 
mental question  it  is  than  any  of  those  which  have  preceded  it,  why  do 
those  muscular  fibers  spontaneously  contract?  What  is  it  that  takes 
place  in  them  when  they  beat,  and  which  stimulates  them  as  we  say  to 
this  contraction  ?    It  is  obvious  that  light  may  be  thrown  upon  this  ques- 

24 


354  MEDICAL   BESEABCH    AND    EDUCATION 

tion  by  investigating  the  conditions  which  favor  or  hinder  the  rhyth- 
mical beat.     Much  of  the  most  brilliant  work  in  this  regard  has  been 
done  here  in  Chicago,  by  Professor  Loeb  and  his  pupils.     They  have 
shown  that  certain  inorganic  ions  (sodium  ions  par  excellence)  have  an 
intimate  and  peculiar  relation  to  the  beat,  and  that  it  will  not  take  place 
if  these  be  absent.    This  at  once  raises  the  question  whether  the  sodium 
ions  are  necessary  in  order  that  the  stimulus  to  contraction  may  be  dis- 
charged, or  in  order  that,  the  stimulus  being  given,  the  muscle  should  be 
able  to  respond  to  it.     And  the  observation  of  Overton,  published  the 
other  day,  that  sodium  chloride  is  peculiarly  necessary  for  the  excita- 
bility of  skeletal  muscle  may  perhaps  be  taken  as  indicating  that  the 
sodium  ions  are  also  necessary  for  the  excitability  of  heart  muscle, 
whether  necessary  or  not  for  the  discharge  of  the  stimulus.    It  is  clear 
that  this  at  once  suggests  the  query,  how  far  the  processes  occurring 
in  the  cardiac  muscle  resemble  those  occurring  in  skeletal  muscle.    We 
can  probably  conclude  that  during  the  actual  contraction  the  processes 
are  very  much  the  same  in  both.    And  this  brings  up  the  question  (I 
am  not,  of  course,  attempting  to  follow  the  historic  development  of  the 
subject)   what  the  changes  are  that  take  place  in  muscular  tissue  in 
general  when  it  contracts.     To  this  question  we  can  give  the  answer 
that  certain  chemical  and  electrical  changes  are  associated  with  the 
contraction.    And  this  in  its  turn  lands  us  in  the  problem  of  the  con- 
nection of  these  changes  with  the  mechanical  changes  in  the  muscle. 
The  precise  relation  of  the  electrical  changes  to  the  contraction  is  still 
undecided.    As  regards  the  chemical  changes,  we  have  advanced  so  far 
as  to  be  quite  sure  that  the  energy  of  the  contracting  muscle  is  derived 
from  the  combustion   (or  the  splitting)   of  certain  substances  in  the 
muscular  fiber.    But  here  for  the  present  we  come  to  a  full  stop,  with 
the  question  in  front  of  us,  how  the  muscle  by  burning  these  substances 
is  able  to  alter  its  form  in  such  a  remarkable  manner.     If  we  could 
solve  that  question  fully  we  should  probably  be  very  near  a  solution  of 
the  general  problem  of  physiology. 

Let  us  take  another  illustration.  During  the  sixteenth  and  the 
seventeenth  centuries  the  whole  of  medicine  was  under  the  sway  of  the 
iatro-chemists,  a  set  of  extremely  theoretical  gentlemen  who  decided 
that  everything,  nolens  volens,  must  be  explained  on  chemical  theories. 
Ferments  were  invented  without  the  least  proof  of  their  existence  to 
explain  the  most  recondite  phenomena,  and  spirits  were  invented  to 


HESEABCE    PROBLEMS  355 

direct  the  work  of  the  ferments.  According  to  Tan  Helmont  the 
Archteus,  a  remarkable  spirit  of  quite  democratic  tastes  and  not  at  all 
above  culinary  pursuits,  gives  his  personal  attention  very  largely  to  the 
function  of  digestion. 

These  vague  notions  lingered  till  the  discovery  by  Spallanzani,  Beau- 
mont, and  many  others  of  the  fact  that  the  action  of  the  gastric  juice 
and  other  digestive  secretions  is  a  chemical  one  which  can  be  exerted 
outside  the  body  as  well  as  in  the  alimentary  canal,  and  with  the  estab- 
lishment of  this  fact  the  whole  fantastic  fabric  of  the  medieval  physi- 
ology of  digestion  came  clattering  to  the  ground.    We  have  now,  thanks 
to  the  work  of  numerous  observers  and  in  recent  years  particularly  of 
Pawlow  and  his  school,  a  very  fair  knowledge  of  how  the  digestive 
juices  act  on  food  substances  and  even  of  how  the  nature  of  the  food 
modifies  the  character  of  the  digestive  juices.     But  when  we  ask  our- 
selves how  tlie  digestive  juices  are  themselves  formed,  we  are  again  at 
the  end  of  our  tether.    We  know  that  the  pancreatic  juice  is  secreted,  as 
we  call  it,  by  the  pancreas,  that  the  gastric  juice  is  secreted  by  the 
gastric  glands,  and  so  on.    But  we  do  not  at  all  know  how  it  is  that  from 
the  same  liquid,  the  blood  or  the  lymph,  the  gastric  cells  form  pepsin 
and   hydrochloric   acid,   while   the   pancreatic   cells   form   an   alkaline 
secretion  with  perfectly  different  properties.     And  it  is  obvious  that,, 
just  as  in  the  case  of  the  naiscular  contraction,  as  soon  as  we  penetrate 
beyond  the  envelope  and  ask  what  happens  in  the  substance  of  the  fiber 
itself,  by  what  subtle  mechanism  there  is  produced  so  strange,  so  almost 
startling  a  phenomenon  as  contraction,  so  in  the  case  of  the  gland  as 
soon  as  we  penetrate  to  the  boundary  of  the  individual  cell  and  ask  by 
what  subtle  chemistry  such  remarkable  results  as  the  separation  of  an 
acid  from  the  alkaline  blood,  in  the  case  of  the  gastric  juice,  or  a  liquid 
with  a  freezing  point  of  — 1.5°  C.  from  blood  serum  whose  freezing- 
point  is  about  — 0.6°  C.  in  the  case  of  the  urine,  we  are  aware  that  we 
again  stand  in  the  presence  of  the  question  on  what  the  peculiar  prop- 
erties of  living  substance  depend,  in  other  words  in  the  presence  of 
the  general  problem  of  physiology. 

This  then  is  what  I  say,  that  no  matter  from  what  standpoint  you 
set  out,  no  matter  what  special  research  you  take  up,  no  matter  what 
particular  organ  you  investigate,  muscle,  nerve,  organs  of  special  sense, 
tissues  of  digestion,  mechanisms  of  reproduction,  elephant  or  bacterium, 
a  man's  brain  or  a  blade  of  grass,  if  you  push  your  enquiries  you  always 


356  MEDICAL   BESEABCE   AND   EDUCATION 

arrive  at  questions  which  can  only  be  settled  by  a  knowledge  of  the 
physico-chemical  constitution  of  living  matter.  And  from  this  I  draw 
the  conclusion  that  all  physiological  problems  are  important  as  regards 
the  development  of  the  science  if  only  they  are  studied  from  the  proper 
standpoint,  and  that  all  the  methods  which  are  useful  for  the  study  of 
particular  problems  are,  if  intelligently  employed,  methods  which  are 
either  capable  of  throwing  light  on  the  general  problem  or  of  aiding  in 
its  definition.  But  the  study  must  have  a  definite  end  in  view.  A  well- 
thought-out  program  with  a  question  propounded  to  which  a  definite 
answer  in  one  direction  or  the  other  can  be  given  (still  better  if  the 
answer  be  a  quantitative  one),  a  definite  use  of  methods  for  the  attain- 
ment of  this  answer,  and  a  proper  apprehension  of  the  relations  of  the 
answer  to  other  ascertained  facts,  these  qualities  are  of  the  essence  of 
true  research.  I  have  heard  the  story  told  that  a  new  professor  ap- 
pointed to  the  chair  of  physiology  in  a  famous  European  university 
where  at  the  time  the  necessity  for  research  was  not  very  clearly  recog- 
nized, after  getting  his  laboratory  in  working  order  and  teaching  begun, 
bethought  himself  that  it  would  be  appropriate  to  start  some  experi- 
ments. He  therefore  consulted  with  a  young  member  of  his  staff  as  to 
what  the  research  should  be,  and  after  much  communing  they  deter- 
mined that  it  should  be  a  research  on  a  rabbit.  I  need  not  say  that  a 
research  on  a  rabbit  is  no  research  at  all.  Mere  fumbling  about  a 
laboratory  in  the  hope  that  one  may  strike  upon  something  new  is  very- 
different  from  true  investigation. 

Reasons  for  the  Choice  of  a  Particular  Prohlem. — "While  it  is  true 
that  any  problem,  if  followed  into  all  its  consequences,  is  important  be- 
cause it  brings  us  at  last  face  to  face  with  fundamental  problems,  there 
are  of  course  at  any  given  stage  in  the  development  of  a  science  certain 
questions  or  certain  lines  of  work  which  possess  a  peculiar  interest  and 
importance  in  themselves.  Very  often  it  happens  that  the  development 
of  the  sciences  most  immediately  accessory  to  physiology,  anatomy, 
physics  and  chemistry,  places  in  our  hands  knowledge  or  methods  which 
determine  the  most  promising  direction  of  physiological  investigation 
at  any  particular  time.  The  mere  mental  fermentation  which  a  stri- 
king advance  in  any  one  science  engenders  in  the  minds  of  workers  in 
other  sciences  is  apt  to  give  them  a  bias  in  a  particular  direction,  some- 
times with  favorable,  but  at  other  times  it  must  be  said  with  unfavorable, 
results,  on  the  development  of  their  own  proper  studies.    If  we  study  the 


BESEAECH   PROBLEMS  357 

history  of  physiology  nothing  will  strike  us  more  forcibly  than  the  fact 
that  at  different  epochs  it  has  presented  very  different  aspects.  And 
often  the  transformation  from  one  predominant  aspect  to  another  has 
been  due  to  such  a  stimulus  from  without  as  I  have  alluded  to.  The 
great  discoveries  of  the  Italian  anatomists  after  the  Eenaissance  made 
physiology  anatomical.  The  separation  of  the  body  into  organs  of 
different  function  became  its  prime  task.  The  genius  of  Descartes  gave 
it  a  mechanical  aspect.  The  appearance  of  the  new  chemistry  was  the 
signal  for  the  subjection  of  physiological  as  well  as  medical  science  to 
the  sway  of  the  iatro-chemists.  The  iatro-mathematical  school  suc- 
ceeded the  iatro-chemical.  It  flourished  especially  in  England,  where 
the  contemporaries  of  Newton  were  fired  with  the  idea  of  explaining 
all  the  actions  of  the  body  in  health  and  disease  by  the  new  mathe- 
matics. In  the  first  part  of  the  nineteenth  century  the  note  became 
predominantly  physical,  when  Hering  measured  the  circulation  time 
and  Volkmann  the  linear  velocity  of  the  blood,  when  Ludwig  intro- 
duced the  modern  methods  for  measuring  blood  pressure,  and  Helm- 
holtz  analyzed  the  vowel  sounds  and  made  his  great  contributions  to 
physiological  optics,  and  when  du  Bois-Eeymond  expanded  electro- 
physiology  into  a  science.  As  the  nineteenth  century  grew  older 
the  aspect  of  physiology  became  more  and  more  chemical,  this  change 
being  stimulated  especially  by  the  advance  of  organic  chemistry.  And 
now  the  prevailing  aspect  is  changing  again  to  the  physical-chemical, 
owing  to  the  great  development  of  molecular  physics  and  physical 
chemistry. 

In  the  science  of  physiology,  as  in  most  others,  there  is  another  reason 
which  often  confers  importance  upon  a  question,  sometimes  out  of  pro- 
portion to  its  intrinsic  value  if  considered  merely  in  relation  to  the 
development  of  the  science.  I  suppose  there  may  be  some  physiologists, 
a  very,  very  few,  I  believe,  to  whom  the  fact  that  their  science  has  a 
practical  value  to  mankind  is  positively  distasteful,  just  as  there  are 
said  to  be  pure  mathematicians  who  devoutly  pray  that  their  achieve- 
ments in  the  world  of  symbols  may  be  of  no  use  to  anybody.  But  I 
confess  that  to  me,  and  I  do  not  doubt  to  the  vast  majority  of  my 
brother  physiologists  (although  they  assuredly  will  not  go  so  far  as 
Bacon,  who  says  in  the  "  Novum  Organum  "  that  "  the  real  and  legiti- 
mate goal  of  the  sciences  is  the  endowment  of  human  life  with  new 
inventions  and  riches"),  it  is  a  cherished  thought  that  our  science  is 


358  MEDICAL    BESEAECH    AND    EDUCATION 

and  must  ever  be  one  of  the  chief  cornerstones  of  practical  medicine. 
It  is  a  dear  and  a  cherished  thought  that  while  all  our  labor  is  tending 
surely  to  the  increase  of  our  knowledge  of  man  and  of  his  relations  to 
the  world  around  him,  not  a  little,  and  indeed  an  increasing  proportion 
of  our  work  is  being  practically  applied  to  the  alleviation,  the  cure  or  the 
jDrevention  of  disease,  to  secure  for  the  toiler  in  the  factory  and  the 
mine,  for  the  salesgirl  in  the  store,  and  for  the  sailor  in  his  ship,  for  the 
soldier  in  his  barracks,  ay,  and  for  the  prisoner  in  his  cell,  to  secure  for 
the  child  in  the  schoolroom,  the  playground  and  the  home,  the  condi- 
tions needed  for  healthy  life  and  work  and  for  physiological  devel- 
opment. 

Some  Important  Special  Prohlems. — I  pass  now  to  the  considera- 
tion of  some  of  the  more  important  special  problems.  Among  the  most 
important  of  the  present-day  problems  of  physiology,  in  my  opinion, 
is  the  influence  of  ions  on  the  life  phenomena  and  therefore  on  the 
living  substance  of  cells.  It  would  be  like  carrying  coals  to  Newcastle 
were  I  to  dilate  upon  this  theme  in  the  University  of  Chicago,  which 
the  work  in  the  physiological  laboratory  on  the  effect  of  ions  upon  the 
absorption  of  water  by  muscles,  on  the  role  of  ions  in  chemotropic 
phenomena,  and  their  influence  upon  the  development  of  eggs,  fertilized 
and  unfertilized,  has  rendered  one  of  the  greatest  centers  of  physio- 
logical research  in  this  country.  Such  experiments  are  calculated  to 
throw  a  flood  of  light  upon  the  physico-chemical  constitution  of  living 
matter. 

But  it  is  becoming  increasingly  clear  that  to  understand  the  cell  we 
must  not  only  study  the  influence  of  substances  of  all  kinds  on  the 
cytoplasm  and  the  nucleus  once  they  have  passed  through  the  cell- 
envelope  and  the  nuclear  membrane,  but  we  must  study  the  nature  of 
these  envelopes,  their  permeability  for  various  bodies,  the  relations  of 
this  permeability  to  their  physico-chemical  constitution,  and  the  altera- 
tions which  it  undergoes  under  various  conditions.  Since  I  have  a 
personal  interest  in  this  phase  of  the  subject  I  may  perhaps  be  pardoned 
for  speaking  of  it  in  some  little  detail. 

More  than  five  years  ago,  starting  from  the  experimental  fact  that 
the  colored  corpuscles  of  the  blood,  as  well  as  pus  corpuscles  and 
lymphocytes,  have  an  extremely  low  electrical  conductivity  in  com- 
parison with  the  serum,  a  circumstance  which  is  due  to  the  relatively 
small  permeability  of  the  envelope  of  the  corpuscles  for  the  ions  of  the 


BESEASCE   FSOBLEMS  359 

serum  and  for  the  ions  in  the  corpuscles  themselves  or  for  some  of 
these,  I  ventured  on  the  generalization  that  the  envelopes  of  all  cells 
are  relatively  impermeable  to  the  ions  of  the  liquids  with  which  they  are 
in  contact  and  to  the  free  ions  present  in  the  cell  contents.     I  reached 
this  conclusion  partly  on  the  general  ground  that  there  is  in  many  cases 
at  any  rate  a  marked  difference  in  the  inorganic  constituents  of  the 
cells  and  the  surrounding  liquids,  an  argument  which  Overton  has  quite 
recently  emphasized  in  the  case  of  striped  muscle.     I  further  argued 
that  the  well-known  fact  that  the  apparent  transverse  resistance  of 
nerve   is   much   greater   than   the   longitudinal   resistance,   receives    a 
natural  explanation  on  the  assumption  that  the  nerve  fibers  are  sur- 
rounded by  badly  conducting  envelopes.    In  addition  I  pointed  out  that 
the  phenomena  of  polarization,  including  the  electrotonic  currents  both 
of  medullated  and  of  non-medullated  nerve  fibers,  as  well  as  other  elec- 
trical phenomena  both  of  nerve  and  muscle,  with  the  alterations  pro- 
duced in  them  by  the  death  of  the  tissue,  could  also  be  explained  by 
the  presence  of  a  badly  conducting  envelope.     I  then  stated  a  general 
line  of  research  in  the  following  words,  "  Assuming  then  for  the  present 
without  attempting  to  give  formal  proof  of  the  assumption  that  in 
general  the  cells  of  the  animal  body  are  bounded  by  an  envelope  rela- 
tively impermeable  to  the  ions  of  the  extra-  and  intra-cellular  liquids, 
it  becomes  of  interest  to  determine  the  degree  of  permeability  of  the 
envelope  for  as  many  different  kinds  of  cells  as  possible  and  for  as  many 
different  substances  as  possible/'  and  in  particular  the  conditions  under 
which  this  permeability  is  altered.     Since  that  time  the  greater  portion 
of  such  leisure  as  I  have  been  able  to  snatch  from  the  all-devouring  maw 
of  professional  routine  has  been  devoted  to  this  inquiry,  and  results  have 
been  obtained  which  seem  to  set  in  a  clearer  light  the  peculiar  relations 
of  these  envelopes,  these  peripheral  layers,  these  frontier  films,  if  you  will, 
to  the  contents  of  the  cell,  on  the  one  hand,  and  to  the  extracellular 
liquids  with  which  the  cell  is  in  contact  and  with  which  it  traffics, 
on  the  other. 

With  regard  to  other  tissues  than  those  free  cells  I  have  already 
mentioned  the  circumstances  which  render  it  extremely  probable  that 
similar  envelopes  of  low  permeability  surround  the  contractile  sub- 
stance of  muscle  and  the  conducting  substance  of  nerve.  Quite 
recently  Macdonald  has  published  an  important  paper  in  which  he 
brings  forward  strong  evidence  that  the  current  of  rest  in  nerves  may  be 


360  MEDICAL   EESEABCH   AND   EDUCATION 

thus  explained.  Bernstein,  only  a  few  weeks  ago,  has  adduced  reasons 
founded  on  the  change  which  the  electromotive  force  of  the  current  of 
rest  of  muscle  and  nerve  undergoes  as  the  temperature  is  altered,  for 
the  conclusion  that  this  current  is  what  is  called  a  "  concentration  cur- 
rent," i.  e.,  is  due  to  the  physical  process  of  diffusion  and  not  to  a 
chemical  process.  The  production  of  such  a  concentration  current  can 
be  explained  either  on  the  alteration  theory  by  the  formation  at  the 
cross  section  of  an  organic  electrolyte  whose  ions  have  different 
velocities  in  the  fiber  and  sheath,  or  on  the  membrane  theory  with  the 
aid  of  electrolytes  (mainly  inorganic  salts)  preexisting  in  the  fibers 
or  fibrils,  under  the  assumption  that  the  living  plasma  membranes 
(what  we  call  envelopes)  of  the  fibers  or  fibrils  are  impermeable  or  with 
difficulty  permeable  for  one  or  both  ions.  Strong  has  also  elaborated  a 
theory  which  seeks  to  explain  both  the  current  of  rest  and  the  negative 
variation  as  due  to  the  core-model  structure  of  the  nerve.  And  Boruttau 
with  a  core-model  consisting  of  gelatine  cylinders  of  potassium  chloride 
solution  surrounded  by  a  mantle  of  0.6  per  cent,  sodium  chloride  solution 
has  actually  reproduced  certain  of  the  electrical  phenomena  of  nerve,  and 
believes  that  all  of  the  electrical  -phenomena  of  active  nerve,  including 
the  action  current,  can  be  explained  by  its  properties  as  a  core-conductor. 
On  this  hypothesis  the  peculiar  permeability  af  the  envelope  for  elec- 
trolytes must  necessarily  play  an  important  part  in  the  conduction  of 
the  nerve  impulse. 

As  a  matter  of  fact,  too,  in  all  work  on  the  action  of  ions  on  the 
living  substance  the  infiuence  of  the  permeability  of  the  cell  envelope 
has  to  be  taken  into  account.  Thus  it  is  perfectly  possible  that  the 
presence  of  ions  of  one  kind  may  prevent  the  entrance  of  ions  of 
another  kind  into  a  cell.  In  this  case  what  might  look  like  an  antago- 
nistic action  of  two  kinds  of  ions  on  the  protoplasm  might  in  reality 
be  due  merely  to  an  altered  permeability  of  the  membrane.  For 
example,  the  action  of  calcium  in  neutralizing  the  ill  effects  of  chlorine 
ions  on  the  heart  muscle  might  be  due  to  a  diminished  permeability  of 
the  envelopes  of  the  muscular  fibers  to  the  chlorine  ions,  produced  by 
the  calcium  ions.  I  need  hardly  remark  that  although  the  cardiac 
muscular  fibers  have  no  sarcolemma  I  still  conceive  of  them  as  possess- 
ing a  physiological  envelope. 

It  is  to  be  hoped  that  the  further  study  of  the  permeability  of  the 
envelopes  of  different  kinds  of  cells  may  throw  light  on  their  selective 


EESEASCH   PROBLEMS  361 

powers.  I  have  shown,  for  example,  that  the  relatively  great  permeability 
of  the  red  corpuscles  for  ammonium  chloride  as  compared  with  sodium 
chloride  depends  not  upon  their  life,  but  upon  their  structure,  and  that 
it  is  not  abolished  by  fixing  with  formaldehyde.  The  action  on  the 
envelopes  and  cell  substance  of  bodies  which  are  lytic  for  particular 
kinds  of  cells,  for  example,  haemolytic  agents  (chemical  and  biological) 
in  the  case  of  blood  corpuscles,  and  the  specific  lysins  in  the  case  of  other 
cells,  is  also  a  promising  field  of  research.  In  this  connection  the 
discovery  of  the  so-called  specific  precipitins  has  raised  a  host  of  inter- 
esting questions.  It  may  be  said  in  a  general  way  that  if  we  inject 
repeatedly  into  the  peritoneal  cavity  of  an  animal  of  a  given  species, 
the  blood  of  another  species,  the  serum  of  the  first  animal  will  produce 
a  precipitate  in  the  blood  of  any  animal  of  the  second  species,  but  not 
in  the  blood  of  an  animal  of  a  third  species.  For  example,  if  a 
rabbit  be  injected  with  human  blood,  its  serum  will  cause  a  precipitate 
in  human  blood,  but  not  in  the  blood  of  a  dog  or  a  cat.  According  to 
Griinbaum's  observations,  however,  a  precipitate  indistinguishable  by  the 
ordinary  method  of  procedure  from  that  obtained  with  human  blood  is 
given  by  the  rabbit's  serum  with  the  blood  of  the  anthropoid  apes.  Such 
results  throw  a  vivid  light  on  blood  relationship  and  give  a  biological 
meaning  to  the  term  which  could  hardly  have  been  anticipated.  It  need 
scarcely  be  pointed  out  that  a  reaction  of  this  kind,  if  perfected  and 
rendered  sharper  and  more  delicate,  might  even  aid  the  zoologist  in  the 
grouping  of  animals. 

Another  line  of  work  which  seems  hopeful  is  the  investigation  of  the 
so-called  colloid  solution.  Considering  the  haemoglobin  in  the  colored 
corpuscles  as  probably  in  a  state  of  colloid  solution,  I  made  a  study  of 
the  action  of  laking  agents  in  causing  intraglobular  crystallization  in 
Nedurus  corpuscles  and  obtained  what  seem  to  be  rather  suggestive 
results.  It  is  possible  that  investigation  of  the  influence  of  ions  on 
this  phenomenon  might  throw  light  upon  the  colloid  condition  and  upon 
the  circumstances  under  which  the  equilibrium  is  upset. 

In  a  word,  the  whole  subject  of  the  chemistry  and  physical  chemistry 
of  cells  presents  an  attractive  field.  A  great  elaboration  of  micro- 
chemical  methods  is  much  to  be  desired. 

Then  again  there  is  the  problem  of  absorption  from  the  alimentary 
canal,  and  the  relations  of  osmosis  and  other  physical  processes  to  it; 
there  is  the  problem  of  secretion,  and  the  investigation  of  specific 


362  MEDICAL   BESEABCH   AND   EDUCATION 

stimuli  to  secretion  like  the  newly  discovered  body  secretin,  which  is 
formed  in  the  mucous  membrane  of  the  intestine  when  hydrochloric  acid 
comes  into  contact  with  it,  and  which,  passing  to  the  pancreas  by  the 
blood  stream,  excites  a  copious  flow  of  pancreatic  juice.  The  suggested 
gaseous  secretion  in  the  lungs  is  certainly  worthy  of  further  study.  A 
more  minute  investigation  of  the  action  of  secretory  nerves  is  required. 
Numerous  problems  connected  with  the  formation  of  lymph  are  still 
awaiting  solution. 

Nor  in  spite  of  the  enormous  amount  of  work  which  has  been  devoted 
to  metabolism  is  there  any  sign  that  we  have  done  more  than  approach  the 
threshold  of  the  subject.  The  mechanism  of  the  oxidations  and  reduc- 
tions occurring  in  the  body,  the  origin  and  action  of  the  group  of 
oxidizing  ferments  known  as  oxydases,  and  indeed  of  ferments  in  gen- 
eral, including  those  concerned  in  intra-cellular  digestion  of  proteids 
and  the  phenomenon  known  as  self-digestion  or  autolysis  of  the  organs, 
the  steps  by  which  protoplasm  is  built  up  and  decomposed,  all  these 
topics  are  brimful  of  problems.  We  much  need  what  we  may  call  cyto- 
metabolic  studies,  which  will  teach  us  in  what  parts  of  the  cell  particular 
steps  of  metabolism  are  conducted.  Lillie,  for  example,  has  shown  that 
the  nucleus  is  a  special  seat  of  oxidation. 

Then  there  are  the  comparatively  new  fields  of  internal  secretion, 
the  defensive,  adaptive  and  regulative  chemical  mechanisms  of  the  body, 
chemotaxis,  and  the  world-old  problem  of  heredity.  Our  ignorance  of 
the  chemical  and  physical  changes  associated  with  the  functions  of  the 
central  nervous  system  is  practically  complete. 

While  I  indicate  these  as  promising  lines  of  research  I  recognize 
very  well  that  none  of  the  older  fields  is  exhausted.  We  still  need 
much  information  on  the  mere  anatomy  of  the  nervous  mechanisms  that 
control  the  heart,  the  blood  vessels  and  the  respiratory  muscles,  espe- 
cially as  regards  the  afferent  paths.  The  fact  announced  by  Bayliss 
within  the  past  year  that  all  the  vaso-dilators  of  the  hind  limb  and 
intestines  (in  the  dog)  run  in  the  posterior  roots  and  are  therefore  not 
efferent  fibers  in  the  morphological  sense,  but  afferent  fibers  conducting 
nerve  impulses  in  a  direction  opposite  to  the  ordinary  (anti-dromic 
nerve  impulses  as  he  calls  them),  the  revolution  which  the  work  of 
Pawlow  and  his  pupils  has  wrought  in  our  knowledge  of  the  action  of 
the  digestive  juices  on  the  food  and  on  each  other,  the  investigations 
of  Sherrington  and  Grlinbaum  on  the  motor  areas  of  the  anthropoid 


BESEAECH   FHOBLEMS  363 

apes,  which  have  excluded  the  ascending  parietal  convolution  from  a 
place  in  the  motor  region  which  it  had  occupied  undisturbed  for  more 
than  twenty-five  years — these  few  instances  out  of  many  which  might 
be  quoted  should  warn  us  that  there  is  still  rich  browsing  on  the  ancient , 
pastures  of  physiology. 

Methods. — Much  of  what  I  have  said  of  the  problems  is  true  also  of 
the  methods  of  physiology.  All  good  methods  are  of  use.  And  just  as 
the  predominant  aspect  of  the  science  at  a  particular  time  determines 
problems,  so  it  determines  methods.  For  certain  problems  some  of  the 
old  methods  are  very  good  and  some  of  the  new  ones  very  bad.  For 
other  problems  the  old  methods  are  useless.  There  is  a  very  old  method, 
the  oldest,  I  suppose,  of  all  physiological  methods,  which  consists  in 
simply  doing  something  to  a  structure  and  then  looking  and  seeing 
whether  your  interference  has  produced  any  effect.  This  is  the  method 
of  inspection,  and  in  the  hands  of  Langley  it  has  yielded  brilliant 
results  in  the  elucidation  of  the  paths  and  functions  of  the  various  kinds 
of  fibers  in  the  sympathetic  system.  For  other  inquiries  special  instru- 
ments, as  plethysmographs,  cardiographs,  sphvgmographs,  erogographs, 
spectroscopes,  calorimeters,  and  so  on,  and  special  ways  of  using  them, 
must  be  employed. 

I  should  be  sorry  to  jeer  at  such  classical  objects  and  instruments 
of  research  as  "the  frog  and  the  myograph,  the  dog  and  the  kymo- 
graph." I  believe  they  are  invaluable  for  particular  purposes.  But 
there  are  a  thousand  questions  to  which  all  the  muscle  tracings  and 
all  the  blood-pressure  tracings  in  the  world  will  never  return  an 
answer,  and  yet  you  may  get  an  answer  by  the  methods  of  chemical 
analysis.  Then  there  are  numerous  problems,  and  those  among  the 
most  fundamental  which  you  will  never  settle  with  the  balance  and 
burette,  and  which  may  yet  be  solved  by  the  galvanometer,  the  electrom- 
eter, or  the  new  methods  of  physical  chemistry.  And  then  again  there 
are  many  problems  for  the  solution  of  which  we  may  have  to  wait  long  till 
appropriate  methods  are  developed  for  their  attack.  Contrariwise,  new 
methods  will  not  unfrequently  suggest  new  problems. 

If  I  were  to  indicate  any  particular  group  of  methods  which  seem 
to  have  the  promise  of  the  future  I  should  be  inclined  to  lay  stress  upon 
the  methods  of  physics  and  of  physical  chemistry.  Of  all  sciences 
physics,  "  the  great  mother  of  the  sciences,"  to  use  Bacon's  phrase,  is  the 
most  indispensable  to  the  physiologist.     Mathematics,  as  being  insepa- 


364  MEDICAL   BESEAECH   AND    EDUCATION 

rably  intertwined  with  physics  and  physical  chemistry,  is  also  of 
importance,  although  at  present  its  field  of  application  is  much  more 
limited  in  physiology  than  in  physics  because  our  science  is  at  present 
much  less  a  quantitative  one  than  physics. 

I  do  not  know  whether  I  ought  to  include  it  among  the  methods,  but 
I  can  not  help  thinking  that  perhaps  the  most  important  method  of  all 
is  the  organizatioii  of  our  researches.  By  this  I  mean  that  not  only 
should  the  individual  worker  so  plan  his  work  that  he  will  most  easily 
and  surely  arrive  at  his  goal,  that  not  only  should  the  head  of  a  labora- 
tory take  thought  to  preserve  a  unity  of  plan  and  a  common  impulse  in 
the  work  which  he  directs,  but  that  something  like  a  scientific  clearing- 
house might  be  devised  by  which  coordination  of  work  should  be 
brought  about  between  the  active  laboratories  of  a  country  at  least,  but 
perhaps  in  time  of  the  world.  I  hope  indeed  the  time  will  come  and  I 
think  it  will  come,  although  perhaps  not  for  a  while,  when,  all  the  world 
over,  a  drilled  army  of  workers  shall  devote  their  energies  to  investi- 
gation under  competent  leadership.  Think  of  the  time  and  strength 
now  in  too  many  cases  frittered  away  because  every  man  is  working  in 
his  own  corner.  Think  of  the  waste  in  the  duplication  of  perfectly 
established  results,  the  secrecy,  the  heartburnings,  the  jealousy  and 
bickerings  for  priority  which  that  secrecy  engenders.  Under  a  proper 
system  numerous  zealous  men  whose  labors  are  now  in  great  part  lost, 
because  through  inexperience  or  lack  of  knowledge  they  attack  unsuit- 
able problems  or  attack  suitable  problems  in  a  wrong  way,  would  be  so 
guided  and  inspired  by  others  of  larger  experience  that  the  cumulative 
effect  of  their  work  might  be  great. 

In  conclusion  let  me  say  that  quite  as  important  as  the  choice  and 
the  statement  of  a  problem,  quite  as  important  as  the  choice  and  the  evo- 
lution of  methods  for  its  solution,  is  the  mental  and  I  may  almost  say  the 
moral  attitude  of  the  investigator  toward  his  task.  It  may  seem  super- 
fiuous  to  remark  that  he  must  be  entirely  willing  to  learn  the  truth, 
the  whole  truth  and  nothing  but  the  truth.  But  man  is  naturally  an 
obscurantist.  The  human  mind  is  far  less  open  to  new  truth  than  is 
sometimes  supposed.  There  is  in  the  back  of  the  minds  of  most  of  us  a 
desire  to  preserve  or  to  accept  beliefs  that  are  pleasant  and  flattering. 
Now  it  is  unfortunately  the  case  that  it  is  pleasant  and  flattering  to 
the  investigator  to  find  that  his  new  facts  seem  to  fit  in  with  his  old 
theories  or  with  facts  which  he  has  previously  discovered.     And  to 


BESEABCH   PROBLEMS  365 

nearly  every  one  of  us  a  fact  that  we  expect  to  find  is  more  welcome 
than  the  gaunt  exception  which  refuses  to  be  covered  by  our  theory  and 
whose  rebellious  angles  threaten  to  distort  the  sleek  contours  of  our 
general  law.  Yet  as  Claude  Bernard  has  well  said,  "  It  is  precisely  the 
exceptional  fact  which  is  valuable,  for  it  is  by  following  it  we  shall  dis- 
cover new  truth,  if  a  discovery  is  to  be  made."  Let  me  remind  you 
how  for  long  years  the  doctrine  of  phlogiston,  phantom  of  the  brain  as 
we  now  know  it  to  have  been,  held  sway  over  the  minds  of  acute  and 
truth-seeking  men,  who  in  every  combustion  must  needs  detect  the 
entrance  or  the  exit  of  phlogiston ;  and  how  in  our  own  profession  men 
believed  it  to  be  as  sure  as  any  scientific  fact  can  be  that  copious  blood- 
letting was  beneficial  in  pneumonia.  Eead  Sir  Thomas  "Watson's 
charming  lectures  on  physic,  and  you  will  see  that  this  was  not  the 
belief  of  ignorant  quacks,  but  of  men  quite  as  acute,  quite  as  well  up  in 
the  science  of  their  time  as  any  of  your  contemporaries.  All  this  should 
teach  us  humility,  that  humility  which  according  to  Faraday,  the 
greatest  experimental  physicist  of  his  day  and  one  of  the  humblest- 
minded  of  men,  should  be  the  first  and  the  last  step  of  education.  At 
the  same  time,  there  is  a  scientific  use  of  the  imagination  which  is  some- 
times of  the  utmost  value  in  unraveling  the  complexity  of  things  and 
which  no  one  employed  more  boldly  than  did  Faraday  himself.  If  I  may 
be  allowed  to  paraphrase  a  favorite  remark  of  Sir  Henry  Lawrence, 
the  hero  of  Lucknow,  "that  it  is  the  due  admixture  of  romance  and 
reality  which  best  carries  a  man  through  life,"  I  would  say  that  it  is 
the  due  admixture  of  imagination  and  self-criticism  which  constitutes 
the  most  valuable  ingredient  in  the  mental  outfit  of  the  physiologist. 

One  word  more  and  I  have  done.  I  do  not  like  to  prophesy.  It  is  a 
dangerous  habit.  But  you  will  see,  I  think,  that  there  lies  ahead  of  us 
in  physiology  a  period  of  active  and  fruitful  expansion.  There  will 
be  no  lack  of  problems  in  our  day.  The  goal  of  physiology  and  medical 
research  is  still  infinitely  distant,  for  with  every  new  advance  new 
prospects  open,  new  questions  suggest  themselves  in  a  series  that  seems 
endless.  To  the  physiologist,  of  course,  as  to  other  men  the  question 
comes  at  times  with  crushing  force,  "What  profit  is  there  in  all  our 
labor  that  we  do  under  the  sun  ?  "  \Yhen  we  thus  falter  in  the  march, 
baffled  by  that  subtlety,  that  obscurity  of  things  of  which  Bacon  speaks 
so  frequently  in  the  "  Novum  Organum,"  we  may  find  comfort  in  the 
thought  that  every  fragment  of  real  work  is  bringing  nearer  for  man 


366  MEDICAL   BESEABCH    AND    EDUCATION 

the  day  of  knowledge  and  therefore  the  day  of  power.  Some  day  perhaps 
the  mystery  of  life  and  being  which  presses  on  the  physiologist  as  on 
other  men,  and  indeed  with  a  double  weight,  may  be  solved.  Some  time 
perhaps  man  may  know  not  only  what  he  is,  but  why  he  is.  To-day, 
after  but  three  thousand  years  of  history  and  three  hundred  of  science, 
it  is  indeed  difficult  to  imagine  how  this  can  be.  We  can  only  trust  that 
it  may  be.  Some  far-off  to-morrow  may  arrive  when  the  clearer  vision 
of  a  million  years  of  science  and  of  history  may  fathom  the  secret  and 
read  the  reconcilement  of  the  hopes  and  the  destiny  of  man. 

"A  hair,  they  say,  divides  the  false  and  true; 
Yes;  and  a  single  Alif  were  the  clue, 
Could  you  but  find  it,  to  the  Treasure-house, 
And  peradventure  to  the  Master  too. ' ' 


ON"  THE   IMPROVEMENT    OF   MEDICAL   TEACHING^ 

By  Dr.  C.  M.  Jackson 

Professor  of  Anatomy  in  the  Medical  School  op  the 
University  of  Minnesota 

The  watchword  of  the  present  is  eonservation.  Especially  in  the 
industrial  world  it  has  been  shown  that  great  improvement  is  possible 
by  tlie  elimination  of  needless  waste  of  time  and  energy.  Though  not 
yet  so  clearly  recognized,  this  is  equally  true  in  the  field  of  education. 
Teachers,  especially  those  in  the  higher  institutions  of  learning,  are 
notoriously  neglectful  of  the  principles  and  technique  of  their  profes- 
sion. Unquestionably  this  results  in  great  losses  due  to  inefficient 
methods  of  teaching.  These  losses,  in  medical  education,  may  be  con- 
servatively estimated  at  twenty  to  twenty-five  per  cent.  In  other 
words,  the  adoption  of  more  efficient  methods  of  teaching  would  prob- 
ably enable  us  to  gain  the  equivalent  of  a  whole  year  within  the  time 
now  devoted  to  the  four  years'  curriculum.  Is  not  the  possibility  of 
such  a  tremendous  saving  well  worth  our  serious  consideration? 

At  the  outset,  it  should  be  clearly  understood  that  uniform  methods 
of  teaching  are  neither  necessary  nor  desirable.  The  methods  in  detail 
must  be  determined  by  the  individual  teacher  to  meet  best  the  varying 
local  conditions.  But  equally  true  is  the  important  fact  that  all  effi- 
cient methods  of  teaching  must  be  based  upon  well-known  and  well- 
established  principles  of  pedagog5^  Efficient  teaching  requires  three 
essential  conditions:  (1)  complete  mastery  of  the  subject-matter  on  the 
part  of  the  teacher;  (2)  a  clear  notion  of  the  aim  of  the  teaching;  and 
(3)  well-chosen  methods  of  accomplishing  the  aim.  The  first  and  most 
essential  condition,  that  the  teacher  must  be  a  master  of  his  subject,  is 
everywhere  clearly  recognized,  and  will  not  be  discussed  in  the  present 
paper.  The  second  and  third  conditions  are  those  oftenest  overlooked, 
and  it  is  therefore  necessary  to  emphasize  certain  fundamental  prin- 
ciples of  aim  and  methods,  the  neglect  of  which  is  largely  responsible 
for  inefficient  teaching. 

^  Read  at  the  twenty-second  annual  meeting  of  the  Association  of  American 
Medical  Colleges,  Chicago,  February  28,  1912.  Published  in  Science,  N.  S.,  Vol. 
XXXV.,  No.  902,  pp.  566-571,  April  12,  1912. 

367 


368  MEDICAL   BESEABCE   AND   EDUCATION 

In  the  first  place,  let  us  therefore  consider  the  aim  of  medical 
education.  In  this  all  will  probably  agree  that  the  primary  aim  of 
medical  education  should  be  to  train  efficient  practitioners.^  And  it 
may  furthermore  be  taken  for  granted  that  an  efficient  practitioner  is 
one  who  is  able  to  observe  accurately,  to  think  clearly  and  to  act  wisely 
in  his  medical  practise. 

Keeping  in  view  this  primary  aim  and  ultimate  purpose  of  medical 
education,  to  train  efficient  practitioners,  we  may  next  consider  the 
methods,  the  ways  and  means,  whereby  this  aim  is  to  be  accomplished. 
If  the  end  is  to  be  reached  most  directly,  if  the  student  is  to  be  trained 
most  economically  for  the  greatest  efficiency,  it  is  evident  that  the 
instruction  must  be  adapted  to  his  nature  and  learning  capacity.  How 
shall  this  be  done  ?  Let  us  see  whether  there  is  any  rational  principle 
to  guide  us  in  adapting  our  methods  to  the  nature  of  the  student. 
Upon  this  question  an  important  light  is  thrown  by  the  history  of 
education. 

A  century  ago,  practically  all  teaching  was  based  upon  the  doctrine 
of  authority.  It  was  the  function  of  the  teacher  to  tell  the  student 
what  he  should  know  and  do.  It  was  the  duty  of  the  student  to  be  a 
passive  recipient,  to  follow  faithfully  the  precepts  of  the  teacher.  This 
doctrine  of  authority,  however,  was  found  inefficient  and  has  long  since 
been  abandoned  in  rational  education.  It  is  now  generally  recognized 
that  all  education  really  worth  while  is  based  upon  self -activity.  This 
principle,  advanced  by  Froebel,  is  now  so  thoroughly  established  in 
education  that  it  may  almost  be  taken  as  self-evident.  Self-activity  is 
the  keynote  of  modern  pedagogy.  And  yet,  while  recognized  in  theory, 
this  fundamental  principle  is  often  almost  totally  neglected  in  practise. 
In  the  light  of  this  principle  of  education  by  self-activity  let  us  review 
briefly  certain  phases  of  methods  in  medical  teaching. 

In  developing  the  self-activity  of  the  student,  it  is  evident  that  the 
methods  first  of  all  must  arouse  his  interest  and  attention.  Interest 
we  know  to  be  most  intense  in  things  which  satisfy  conscious  needs. 
Now  the  medical  student  wants  above  all  to  be  a  good  practitioner. 
If  he  knows  that  a  certain  thing  will  help  him  to  accomplish  this,  he 
is  intensely  interested,  and  will  exert  an  active  effort  to  secure  it. 
"  The  mind  interprets  impressions  from  without,  not  according  to  their 

*  In  addition  to  the  education  of  practitioners,  the  medical  school  has  other 
important  functions,  such  as  the  advancement  of  medical  science  through  original 
investigation,  but  these  are  not  within  the  scope  of  the  present  paper. 


MEDICAL    TEACHING  369 

intrinsic  nature,  but  according  to  their  relation  to  the  needs  of  the 
organism"  (Bagley).  Common  sense  and  good  pedagogy  therefore 
agree  that  in  teaching  any  subject  in  the  medical  curriculum,  the 
teacher  should  make  sure  that  the  student  realizes  its  bearing  upon  his 
later  work. 

Some  may  conclude  from  the  foregoing  that,  since  time  is  limited, 
only  the  so-called  "  practical "  facts,  those  that  are  of  obvious  utility  in 
the  practise  of  medicine,  should  be  taught,  and  that  no  time  should  be 
wasted  on  "  theoretical "  aspects.  While  this  argument  may  appear 
plausible  at  first  glance,  its  fallacy  is  apparent  on  closer  examination. 
In  the  first  place,  it  is  impossible  in  any  given  subject  to  select  out 
only  those  facts  which  may  later  be  needed.  Moreover,  even  if  such 
facts  could  be  selected,  it  would  be  impossible  to  teach  them  as  bare, 
empirical  facts,  in  such  a  way  that  the  student  could  understand, 
remember  and  utilize  them,  without  a  comprehension  of  the  science  of 
which  they  form  a  part.     The  "  theoretical,"  as  Bagley  states, 

contributes  to  the  coherence  of  the  various  facts  and  principles  as  Tcnowledge. 
Its  value  can  not  be  disputed,  for  any  attempt  to  ' '  cut  out ' '  the  ' '  impractical ' ' 
parts  invariably  results  in  the  inefficient  functioning  of  the  remainder.  Short 
courses  that  give  only  the  essentials,  fifth-rate  colleges  and  normal  schools  that 
educate  you  while  you  wait,  are  sufficiently  damned  by  their  own  products. 

There  is,  it  must  be  acknowledged,  some  truth  in  both  the  "  prac- 
tical "  and  the  "  theoretical "  points  of  view.  The  best  methods  of 
teaching  will,  therefore,  utilize  both.  While  each  subject  should  be 
taught  from  the  theoretical,  scientific  point  of  view,  at  the  same  time 
its  practical  application  should  be  kept  constantly  in  mind.  In  select- 
ing material  to  develop  the  essential  principles,  those  facts  should  be 
chosen  which  will  also  probably  be  of  greatest  intrinsic  value  for  later 
work.  Anatomy,  for  example,  should  be  taught,  not  as  a  mass  of 
empirical  facts,  but  as  a  special  branch  of  biological  science.  But  in 
selecting  from  the  huge  mass  of  available  data  the  facts  necessary  to 
illustrate  the  science  of  anatomy,  so  far  as  possible  those  facts  should 
be  chosen  that  are  also  of  direct,  intrinsic  value  in  physiology,  pathol- 
ogy and  clinical  medicine. 

If  this  plan  were  consistently  followed  out,  and  everything  excluded 
excepting  facts,  especially  those  of  intrinsic  value,  necessary  to  develop 
a  scientific  basis,  a  "  working-knowledge,"  for  each  branch  of  study, 
the  amount  of  siibject-matter  presented  in  each  could  be  greatly  re- 
duced.    We  all  recognize  that  the  curriculum  is  now  overloaded.     It  is 

25 


370  MEDICAL   EESEASCH   AND   EDUCATION 

impossible  to  teach  so  much  and  teach  it  well.  "What  men  need" 
(according  to  Huxley)  "  is  as  much  knowledge  as  they  can  assimilate 
and  organize  into  a  train  for  action." 

To  develop  in  accordance  with  the  foregoing  plan  the  most  effective 
methods  of  teaching,  it  is  evident  that  each  teacher  must  understand 
the  curriculum  as  a  whole.  The  laboratory  man  must  be  familiar  with 
the  clinical  work.  But  this  is  not  all.  Since  good  teaching  must  take 
into  account  that  which  has  gone  before  as  well  as  that  which  is  to  fol- 
low, it  is  equally  evident  that  the  clinical  man  must  be  familiar  with 
laboratory  subjects  and  methods.  We  can  not  expect  the  best  results 
in  medical  education  until  there  is  a  better  understanding  and  more 
cooperation  between  teachers  of  the  various  subjects  all  along  the  line. 
As  medicine  progresses,  all  phases  appear  more  clearly  as  varied  mani- 
festations of  the  same  underlying  biological  science,  and  only  when  this 
is  realized  will  the  clinical  and  laboratory  work  be  more  closely  knitted 
together. 

We  have  seen  that  to  interest  the  student  and  arouse  him  to  self- 
activity,  he  should  be  made  to  realize  that  each  subject  contributes  an 
essential  part  in  training  him  for  the  desired  end.  We  may  next  in- 
quire as  to  how  he  must  be  self-active.  Since  efficiency  in  practise  con- 
sists in  accurate  observation  and  reasoning,  res-ulting  in  wise  action  in 
dealing  with  medical  problems,  his  training  should  develop  self-activity 
in  these  very  lines.  He  must  observe,  think  and  act  for  himself.  For 
this  purpose  almost  ideal  facilities  exist  in  our  laboratories  and  clinics. 
Unfortunately,  however,  we  are  far  from  utilizing  these  facilities  to 
their  fullest  extent.  Our  methods  fail  to  make  the  student  self-active, 
especially  in  observation  and  reasoning. 

First  we  may  consider  observation.  This  can  be  cultivated  only  by 
actual  observation  of  medical  phenomena  on  the  part  of  the  student. 
It  is,  however,  a  surprising  fact  that  in  many  laboratories  and  clinics 
there  is  no  opportunity  for  the  student  to  make  an  original  observation. 
Why?  Simply  because  through  a  pernicious  lecture  system  he  has 
already  been  told  all  about  what  he  is  to  see,  before  he  has  ever  had  a 
chance  to  observe  it  for  himself. 

It  is  furthermore  a  fundamental  law  of  learning  (technically  the 
doctrine  of  apperception)  that  we  can  not  comprehend  new  facts  except 
upon  the  basis  and  in  terms  of  previous  concrete  experience.  Hence 
the  dictum :  "  In  teaching,  always  proceed  from  the  concrete  to  the 


MEDICAL    TEACHING  371 

abstract;  from  the  particular  to  the  general;  from  the  known  to  the 
unknown."  It  is  therefore  evident  that  to  give  lectures  preceding  prac- 
tical objective  study  not  only  prevents  the  exercise  of  original  observa- 
tion, but  also  inverts  the  normal  procedure  in  the  process  of  learning. 

Much  time  and  energy  is  sometimes  thus  wasted  in  trying  to  teach 
by  lectures  what  would  be  quickly  and  easily  comprehended  after  the 
fundamental  data  had  been  acquired  by  objective  study.  In  some 
schools,  for  example,  the  junior  yea,T  is  largely  given  over  to  lectures 
and  other  didactic  work  which  is  supposed  to  prepare  the  students  for 
the  actual  clinical  work,  the  latter  being  chiefly  concentrated  in  the 
senior  year.  This,  it  seems  to  me,  is  a  fundamental  mistake.  If  there 
were  only  one  alternative,  it  would  be  better  to  reverse  this  order, 
giving  the  clinics  first,  and  the  lectures  later.  In  actual  practise, 
however,  they  are  best  intermingled  and  closely  correlated,  care  being 
taken  always  to  provide  the  objective  basis  before  the  more  abstract 
generalizations  are  considered. 

Even  when  the  practical  work  is  placed  first,  however,  it  by  no 
means  follows  that  adequate  training  in  observation  will  result.  In 
both  laboratories  and  clinics  it  is  a  common  practise  as  a  preliminary 
step  to  tell  the  student  (either  orally  or  by  printed  guides)  what  he 
is  to  see.  The  student  thus  is  not  required,  and  indeed  has  no  oppor- 
tunity, to  observe  for  himself.  Practically  all  there  is  left  for  him  to 
do  is  to  verify  what  he  has  already  been  told.  However  valuable  this 
may  be,  it  does  not  develop  power  of  original  observation.  It  is,  of 
course,  desirable  to  precede  all  practical  work  with  a  brief  introduction 
which  will  enable  the  student  to  proceed  intelligently  with  his  work. 
Such  an  introduction,  however,  should  be  merely  for  the  purpose  of 
explaining  technical  procedure  and  of  raising  questions  the  answer  to 
which  the  student  should  seek  by  original  observation. 

The  ideal  plan  is  thus  for  the  student  to  work  out  everything  for 
himself  by  the  method  of  discovery.  This  applies  not  only  to  the  orig- 
inal observations,  but  also  to  the  later  process  of  reasoning,  whereby  we 
proceed  from  particular  data  to  general  conclusions,  and  thence  to 
rational  action.  The  method  of  self-activity  may  therefore  be  expressed 
in  a  negative  way  by  the  following  practical  rules :  Never  tell  a  student 
anything  he  can  observe  for  himself ;  never  draw  a  conclusion  or  solve  a 
problem  which  he  can  be  led  to  reason  out  for  himself;  and  never  do 
anything  for  him  that  he  can  do  for  himself. 


372  MEDICAL    BESEAECH   AND    EDUCATION 

Unfortunately,  however,  there  are  limitations  to  the  application  of 
this  method.  It  is  difficult  to  apply  successfully,  requiring  skill  and 
experienced  judgment  on  the  part  of  the  teacher.  Lack  of  time  would 
moreover  prevent  the  student  from  repeating  the  history  of  the  race  by 
the  method  of  discovery.  But  though  difficult  and  slow  at  first,  by 
working  out  for  himself  at  least  the  fundamental  data,  a  solid  basis  is 
laid  which  makes  possible  more  rapid  progress  later.  Time  lost  at  the 
beginning  is  thus  time  gained  in  the  end.  We  should  therefore  insist 
that  so  far  as  practicable  this  ideal  method  be  applied  for  the  purpose 
of  training  the  student  to  self-activity,  in  developing  his  ability  in 
observation,  reasoning  and  action. 

As  supplementary  to  the  foregoing,  it  is  usually  necessary  to  adopt 
easier  though  less  effective  methods  of  instruction.  Thus  where  neces- 
sary data  can  not  be  secured  by  original  observation,  they  may  be  sup- 
plied by  the  usual  type  of  laboratory  or  clinical  demonstrations,  which 
the  student  can  verify.  Next  in  value  below  this  as  a  means  of  impart- 
ing knowledge  comes  the  informal  lecture  or  recitation,  illustrated  by 
demonstrations,  models,  pictures,  etc.  Next  comes  the  text-book,  and 
lowest  of  all  in  the  scale  is  the  formal  lecture.  Curiously  enough,  the 
lecture  is  also  the  easiest  method,  by  which  apparently  the  greatest 
amount  of  information  is  gained  with  the  leasf  expenditure  of  energy, 
at  least  on  the  part  of  the  student.  But  this  is  a  delusion.  The  knowl- 
edge thus  gained  is  unreal  and  transient.  It  is  "  in  at  one  ear,  and 
out  at  the  other."  As  we  should  naturally  expect  from  the  principle 
of  self-activity,  the  ease  of  the  method  is  apt  to  be  inversely  propor- 
tional to  the  efficiency  of  the  instruction.  In  order  therefore  to  train 
our  students  most  efficiently  in  self-activity,  we  should  use  the  maxi- 
mum amount  of  the  more  difficult  but  more  effective  methods  and  the 
minimum  of  those  easier  but  relatively  inefficient. 

This  will  perhaps  be  made  clearer  by  a  brief  illustration  from  per- 
sonal experience.  To  learn,  for  example,  the  normal  histology  of  any 
given  organ  by  means  of  a  stained  and  mounted  section,  this  should 
first  be  studied  by  original  ohservation.  The  students  observe  the 
structure  with  naked  eye,  low  power  and  high  power  of  the  microscope, 
and  without  previous  description  by  teacher,  book  or  laboratory  outline. 
They  record  their  observations  by  sketches  and  brief  notes.  The  aid  of 
the  teacher  at  this  stage  should  be  restricted  to  questioning  the  indi- 
vidual students  so  as  to  recall  related  facts  previously  studied  and  pre- 


MEDICAL    TEACHING  373 

vent  the  student  from  going  too  far  astra}'.  At  first,  students  are  apt 
to  be  utterly  helpless  when  thus  thrown  largely  upon  their  own  re- 
sources, but  they  soon  develop  surprising  powers  of  observation.  This 
"  investigation  "  occupies  the  first  part  of  the  laboratory  period.  The 
teacher  then  informs  the  class  regarding  the  section  they  have  studied, 
and  discusses  briefly  their  mistakes  of  observation.  He  directs  them 
in  restudying  the  section,  and  in  correcting  their  mistakes.  The  stu- 
dents now  extend  their  knowledge  by  verifying  the  statements  found 
in  their  text-books.  Demonstrations  are  made  to  furnish  additional 
data  and  elucidate  the  more  difficult  points.  Drawings  are  finally  made 
by  the  students,  to  fix  the  corrected  impressions  upon  their  minds.  At 
a  later  class-conference,  the  students  are  led  to  review  the  facts  learned, 
to  correlate  and  interpret  them  and  to  reason  out  general  conclusions 
or  laws  of  structure.  These  laws  they  utilize  and  apply  in  the  subse- 
quent work.  Brief  written  reviews  are  also  frequently  held.  Occa- 
sional lectures  by  the  teacher  elucidate  the  more  difficult  phases,  and 
indicate  the  relations  of  histology  to  physiology,  pathology  and  clinical 
medicine.  The  results  are  satisfactory  as  shown  by  final  examination, 
both  written  and  practical,  and  by  the  extent  to  which  the  students  are 
able  to  retain  and  utilize  their  knowledge  in  later  work. 

The  foregoing  method  illustrates  how  students  may  be  trained  to  self- 
activity  in  observation  and  reasoning,  and  to  a  certain  extent  in  appli- 
cation. The  application  of  the  generalizations  reached  by  observation 
plus  reasoning,  while  essential  in  every  subject,  is  especially  character- 
istic of  the  clinical  work.  That  the  student  should  be  self-active  in  his 
clinical  work,  that  to  acquire  skill  in  the  practical  application  of  his 
previous  knowledge  he  must  "  learn  by  doing,"  is  universally  recog- 
nized. It  is  therefore  unnecessary  to  dwell  upon  this  phase  of  the 
subject.  It  may  be  worth  while,  however,  to  remember  that,  above  all, 
in  the  clinics,  "  tlie  main  business  of  the  teacher  is  to  render  his  services 
unnecessary  "  ( Strayer ) . 

To  summarize  the  foregoing:  it  has  been  maintained  that  in  med- 
ical education  there  is  great  need  of  more  effective  methods  of  teaching. 
Efficient  teaching  requires  a  clear  view  of  the  ultimate  aim,  which  in 
medicine  is  to  train  efficient  practitioners.  To  accomplish  this  aim, 
rational  methods  of  teaching  should  develop  in  the  student  self-activity 
in  observation,  reasoning  and  action.  While  some  may  be  unable  to 
accept  fully  the  ideas  here  presented,  all  will  surely  agree  that  great 


374  MEDICAL   BESEABCE   AND   EDUCATION 

improvement  would  result  if  medical  teachers  would  study  more  care- 
fully their  educational  methods.  The  younger  teachers  who  are  so 
fortunately  located  could  greatly  improve  their  efficiency  by  taking 
work  in  the  schools  of  education  connected  with  the  various  universities. 
Those  unable  to  do  this  should  at  least  study  the  principles  of  pedagogy, 
which  are  available  in  numerous  books.  Although  pedagogical  litera- 
ture deals  chiefly  with  elementary,  rather  than  advanced  or  professional 
education,  it  is  nevertheless  of  great  service,  for  the  same  fundamental 
principles  extend  throughout,  from  the  kindergarten  to  the  university. 
Among  those  books  which  may  be  recommended  as  helpful  are  the  fol- 
lowing: Spencer,  "  Essays  on  Education  "  (a  recent  edition,  with  intro- 
duction by  ex-President  Eliot,  in  the  "  Everyman's  Library  "  series)  ; 
James,  "  Talks  to  Teachers  on  Psychology,"  etc.  (Holt)  ;  Charters, 
"  Methods  of  Teaching  Developed  from  a  Functional  Standpoint " 
(Eow,  Peterson  &  Co.);  Bagley,  "The  Educative  Process"  (Mac- 
millan)  ;  Thorndike,  "  The  Principles  of  Teaching  Based  on  Psychol- 
ogy" (Seller).  And  in  conclusion,  permit  me  to  suggest  that  a  more 
thorough  discussion  of  educational  methods  and  principles  in  our 
association  meetings,  and  also  in  the  faculty  meetings  of  our  various 
medical  schools,  would  result  in  greater  efficiency  in  our  teaching. 


EQUIPMENT   AND   INSTRUCTION   OF   THE  LABORATOEY 

YEARS! 

By  E.  p.  Lyon,  Ph.D.,  M.D., 

Professor  op  Physiology  and  Dean,  lately  at  St.  Louis  University  School 
OF  Medicine,  now  at  the  Medical  School  of  the  University  op  Minnesota 

Befoee  attempting  to  discuss  the  subject  set  before  us,  it  may  be 
well  if  we  agree  as  to  the  function  of  a  medical  school,  and  as  to  the  aim 
of  all  of  us  who  devote  our  lives  to  medical  education.  In  an  address 
last  year.  Dr.  Welch^  said  that  our  object  is  "to  make  good  doctors.^' 
Professor  Minot^  in  his  Washington  University  commencement  address, 
gives  a  more  exact  formulation  in  these  words :  "  The  chief  function  of 
a  medical  school  is  to  produce  practitioners."  Whichever  definition  we 
prefer,  we  doubtless  agree  on  the  main  idea;  and  I  ask  you,  therefore, 
to  bear  in  mind  that  our  purpose  is  to  make  or  produce  something,  and 
that  something  is  a  good  doctor  or  practitioner. 

The  making  of  something  implies  five  factors:  (1)  raw  material; 
(3)  a  model  or  pattern  (which  of  course  may  be  either  substantial  or 
existing  as  an  ideal  in  the  mind  of  the  workman)  ;  (3)  men  to  do  the 
work;  (4)  a  place  to  work  in  and  tools  to  work  with;  (5)  time  to  do  the 
work.    The  results  may  be  bad  from  failure  in  any  of  these  points. 

Our  frequent  considerations  of  entrance  requirements  and  qualifica- 
tions of  students  show  our  interest  in  raw  material.  Our  time-consum- 
ing studies  of  curriculum  and  equipment  give  evidence  that  we  are  con- 
cerned with  tools  and  place  of  work.  Our  occasional  weak  efforts  to  de- 
termine who  are  qualified  instructors  indicate  our  interest  in  workmen. 
Our  discussions  of  four-year,  five-year  and  six-year  courses  reveal  our 
recognition  of  the  time  factor.  "WTiile  our  very  discordant  ideas  as  to 
what  constitutes  a  "good  doctor"  show  how  little  we  have  considered 
the  model  or  pattern  in  our  educational  manufacturing  establishment. 

What  Constitutes  a  "Good  Doctor"? 
What  is  a  "good  doctor"?    Is  he  that  lovable  figure  of  the  "Bonny 
Briar  Bush,"  "  Old  Chester  Stories  "  and  other  contemporaneous  fiction  ? 

*  Published  in  the  American  Medical  Association  Bulletin,  January  15,  1911. 

*  Proceedings  Association  of  American  Medical  Colleges,  1910,  p.  62. 
'Journal  American  Medical  Association,  1909,  Vol.  LIII.,  p.  502. 

375 


376  MEDICAL   BESEABCH   AND   EDUCATION 

I  am  sure  most  of  you  would  say  "  No."  Is  he  the  hermit  of  the  test- 
tube,  incubator  and  centrifuge?  Being  that  kind  of  a  hermit,  I  will 
save  you  the  trouble  by  answering  "  No."  Is  he  the  physician  (too  often 
found  in  medical  faculties)  of  extensive  clinical  training,  who  ridicules 
the  laboratory  and  says  the  microscope  has  no  place  in  medicine  ?  Some 
of  you  will  reply  in  the  negative.  Is  he  that  ignorant  but  honest  man 
found  so  often  as  the  legally  constituted  physician  of  an  ignorant  com- 
munity? Or  is  he  the  equally  ignorant  but  dishonest  individual  who, 
with  or  without  legal  right,  is  the  physician  of  people  less  ignorant  than 
himself  ?  We  are  all  agreed  that  the  "  good  doctor  "  is  neither  he  "  who 
knows  not  that  he  knows  not,"  nor  he  who  veneers  his  ignorance 
with  an  assumption  of  knowledge.  But  we  can  not  agree  exactly 
what  a  "good  doctor"  is.  Some  will  say  "Practical";  some  will 
say  "  Scientific."  Some  will  say  "  Knowledge  " ;  some  will  say  "  Heart." 
In  proposing  to  discuss  the  topic  assigned  to  me  from  the  standpoint 
of  the  pattern  or  model,  I  shall  not  attempt,  therefore,  the  task  of  for- 
mulating in  words  all  the  qualities  of  a  "  good  doctor."  Some  of  them 
fortunately  are  on  the  surface  and  do  not  need  a  psychologist's  analysis 
nor  a  philosopher's  logic,  nor  a  novelist's  rhetoric. 

\  .  An  Accurate  Observer. 

First :  the  "  good  doctor  "  must  be  an  accurate  observer.  His  senses 
must  be  trained  and  alert.  Eye,  ear  and  finger  must  be  sensitive  and 
connected  with  a  brain  which  is  quick  to  recognize  and  discriminate. 
Dr.  Minot,  in  the  paper  already  quoted  from,  has  discussed  this  matter 
fully  and  convincingly.  He  points  out  the  difficulties  and  limitations 
of  accurate  observation;  some  of  them  connected  with  our  imperfect 
sense  organs;  most  of  them,  with  our  imperfect  mental  processes.  We 
can  not  go  into  detail  here,  but  the  upshot  of  the  matter  is  that  the  good 
observer  is  partly  born  and  partly  made.  The  former  moiety  belongs  to 
our  raw  material  and  need  not  be  considered  here.  The  latter  is  of  im- 
mediate interest,  for  we  know  that  the  power  of  observation  can  be  cul- 
tivated. It  improves  by  practise.  Next  in  importance  is  skilled  direc- 
tion or  instruction. 

All  of  the  studies  of  the  fundamental  years  are  suited  to  develop  ob- 
servation. Anatomy  more  than  the  others  is  adapted  to  this  end.  In 
my  judgment  its  presence  in  the  curriculum  is  chiefly  justifiable  on  this 
account,  rather  than  from  its  supposed  practical  value.     Anatomy  is 


EQUIPMENT    AND    INSTEUCTION  377 

concerned  with  a  great  variety  of  complex  structures,  whose  materials, 
textures,  forms,  sizes  and  relationships  constitute  observational  material 
of  the  most  alluring  variety  and  complexity.  Moreover,  the  student 
always  feels  that  the  subject  is  of  practical  importance,  and  this  adds 
an  element  of  interest  on  the  part  of  the  learner  which  gives  to  anatomy 
a  value  for  the  training  of  observation  even  greater  than  that  afforded 
by  its  peculiar  material  and  methods. 

Value  of  Cross  Sections 

I  feel  that  for  the  purpose  we  are  discussing,  namely,  the  developing 
of  powers  of  accurate  observation,  the  study  of  cross  sections  of  the  body 
is  of  greater  value  than  dissection.  No  doubt  each  supplements  the 
other,  but  the  study  of  structures  from  section  to  section  with  their 
variations,  appearances,  disappearances  and  relations  must  be  of  great 
influence  in  stimulating  the  power  to  visualize  or,  as  some  anatomist 
has  put  it,  to  see  the  body  as  if  it  were  transparent,  a  power  so  neces- 
sary to  the  physician  and  surgeon  and  so  impossible  of  acquisition  ex- 
cept on  the  basis  of  accurate  observation  in  the  anatomical  laboratory. 

Like  gross  anatomy,  microscopic  anatomy  in  its  various  divisions, 
such  as  histology  and  embryology,  is  chiefly  an  observational  science. 
Here  we  introduce  the  use  of  instruments  of  precision  as  an  aid  to  ob- 
servation. The  microscope  is  of  the  utmost  importance,  not  on  account 
of  the  immediate  facts  revealed,  valuable  though  these  are;  nor  on  ac- 
count of  its  use  in  diagnosis,  indispensable  though  this  should  be;  but 
chiefly  because  of  the  relation  in  which  it  places  the  observer  with  re- 
spect to  the  objective  world.  The  space  sensations  connected  with  binoc- 
ular vision  and  accommodation  do  not  help  him.  The  third  dimension 
can  only  partially  be  supplied  by  focusing.  If  he  is  to  get  any  idea  of 
solidity  and  relationship,  he  must  be  able  to  visualize.  He  must  add 
field  to  field  and  place  section  upon  section  in  his  mind.  If  I  may 
parody  an  old  adage,  he  must  mix  his  seeing  with  brains.  Indeed  the 
mental  effort  must  here  be  inevitably  the  larger  part  of  observation. 
Microscopic  anatomy  is  justified  on  this  basis  if  no  other. 

Careful  Work  Essential 

If  now  it  is  true  that  anatomy  is  chiefly  to  be  considered  as  an  aid 
to  the  development  of  accurate  observation,  we  immediately  see  the  fu- 
tility of  hasty  and  careless  dissection  and  of  short  perfunctory  courses 


378  MEDICAL   SESEABCH   AND   EDUCATION 

in  histology.  They  defeat  the  very  end  for  which  these  studies  should 
be  undertaken  by  substituting  hazy  impression  for  accurate  observation ; 
carelessness  and  error  for  thoroughness  and  truth. 

What  is  true  of  anatomy  in  the  above  respect  is  true  of  every  other 
science  so  far  as  the  development  of  observational  power  is  concerned.  I 
think,  therefore,  that  we  have  a  scientific  basis  for  the  belief  that  it  is 
not  number  of  facts  that  we  should  attempt  to  demonstrate,  but  rather 
perfect  observation  and  understanding  of  a  few.  Nor  should  we  favor  a 
multiplicity  of  short  courses  of  study.  Intensity  and  accuracy  should  be 
our  watchwords,  rather  than  breadth  and  general  impression.  If  one  is 
turned  rapidly  in  a  circle,  a  thousand  images  flash  across  the  retina,  yet 
one  sees  nothing.  It  is  those  images  that  are  dwelt  on  and  repeated  and 
studied  that  remain  and  strengthen  our  powers  and  become  a  part  of 
ourselves. 

Full-time  Instructors  Essential 

If  it  be  true  that  observing  power  is  a  chief  characteristic  of  the 
"good  doctor,"  and  if  it  be  true  that  anatomy  constitutes  an  excellent 
and  probably  the  best  training  for  acquiring  this  power,  and  if  it  be  true 
that  particular  instruction  and  supervision  are  necessary,  then  it  is  per- 
fectly evident  that  proper  regard  for  the  product  of  our  educational  es- 
tablishment will  make  us  provide  expert  worknien  in  gross  and  micro- 
scopic anatomy.  If  a  man  knows  what  to  see  in  the  human  body,  how  to 
see  it  and  how  to  bring  others  to  see  it,  he  has  enough  to  keep  him  busy. 
He  has  no  time  to  become  competent  in  another  trade  or  profession.  He 
can  not  drive  a  street  car  nor  conduct  a  real-estate  business  nor  practise 
medicine.  Hence,  we  have  the  argument,  from  the  standpoint  of  a  good 
"  output,"  for  the  anatomist  who  shall  give  his  whole  time  to  the  med- 
ical school. 

Essential  Equipment  and  Assistants 

The  same  arguments  that  make  necessary  the  professional  anatomist 
make  equally  indispensable  (1)  a  proper  place  for  him  to  work,  which 
means  not  only  teaching  laboratories,  but  also  research  rooms;  (2)  proper 
material  for  teaching  and  study,  which  means  cadavers,  microscopic 
preparations,  embryos,  animals,  etc.;  (3)  proper  equipment,  which 
means  microscopes,  microtomes,  models,  photographic  and  projection 
apparatus,  books,  periodicals,  etc. ;  (4)  proper  help,  which  means  janitor 
service,  technician,  artist,  etc.  (on  the  universally  acknowledged  eco- 
nomic principle  that  it  does  not  pay  to  have  a  high-priced  man  do  low- 
class  work). 


EQUIPMENT    AND    INSTRUCTION  379 

We  are  driven  by  all  the  foregoing  to  conclude  that  an  institution  is 
failing  in  its  regard  for  its  "  output/' — for  its  "  model,"  the  "  good  doc- 
tor/'— when  it  fails  properly  to  provide  for  the  anatomical  sciences. 

The  "Good  Doctor"  a  Trained  Experimenter 

Besides  being  an  exact  observer,  the  "  good  doctor "  must  be,  in  my 
opinion,  a  trained  experimenter.  In  regard  to  this  statement  there  may 
be  diversity  of  opinion.  When  I  read  it  first  to  my  wife,  she  said, 
"What  I  want  is  a  doctor  who  knows.  Let  him  experiment  on  other 
people.  I  want  him  to  have  his  experimenting  all  done  when  he  comes 
to  me."  Doubtless  this  expresses  very  well  the  general  attitude  of  the 
lay  mind ;  and  this  attitude  may  be  responsible  for  the  ultra  conserva- 
tism of  medicine.  The  doctor  is  afraid  of  being  accused  of  experiment- 
ing with  his  patients.  Nevertheless  he  is  always  doing  so;  and  in  the 
present  lack  of  knowledge  he  must  experiment,  at  least  in  treatment, 
whether  he  wishes  to  or  not.  I  should  perhaps  add  that  by  experiment  I 
do  not  mean  the  use  of  some  new  drug  or  surgical  procedure.  If  the 
physician  tries  the  effect  of  rest,  or  baths,  or  gymnastics,  or  deprivation 
of  coffee,  it  is  just  as  truly  an  experiment  as  a  first  injection  of  salvarsan. 

The  main  difference  between  experimentation  and  ordinary  observa- 
tion is  that,  in  the  former,  the  observer  controls  and  varies  the  condi- 
tions. The  primary  element  of  observation  is  just  as  important  as  ever, 
but  the  equally  important  element  of  controlled  conditions  is  added. 
The  mental  process  is  by  that  addition  made  more  complex.  The  re- 
sults, moreover,  are  more  fruitful  than  those  of  simple  observation,  since 
the  experimenter  can  bring  under  observation  conditions  which  nature 
might  never  produce. 

I  have  said  that  every  "good  doctor"  should  be  a  trained  experi- 
menter. I  believe  that  very  few  are  such.  Most  physicians  do  not  know 
how  to  experiment.  Their  methods  are  at  fault.  Consequently  their 
conclusions  are  of  little  value. 

Principles  of  Experimentation 

The  first  principle  of  experimentation  is  to  vary  but  one  factor  at  a 
time.  If  a  physiologist  is  studying  the  effect  of  load  on  muscular  con- 
traction, he  does  not,  at  the  same  time  that  he  changes  the  load,  also 
change  the  temperature  and  the  stimulus  and  the  speed  of  the  recording 
apparatus.    But  I  have  seen  a  physician  make  all  the  following  changes 


380  MEDICAL   BESEABCH   AND    EDUCATION 

at  one  time:  (a)  put  a  patient  in  bed,  (6)  restrict  his  diet,  (c)  give  a 
saline  cathartic,  (d)  give  some  drug.  Then  he  concludes  that  the  pa- 
tient's changed  condition  is  due  to  the  drug.  This  may  be  true,  but  the 
conclusion  is  not  warranted  from  the  experiment. 

The  second  principle  of  experimentation  is  repetition.  There  may 
be  an  unrecognized  factor.  Therefore,  no  conclusion  can  be  of  general 
application  unless  the  experiment  is  repeated  many  times  with  like  re- 
sults. Of  course  this  is  the  method  of  inductive  logic  in  general ;  but  I 
have  frequently  heard  physicians  remark:  "I  never  use  so  and  so.  I 
tried  it  once  and  it  didn't  give  good  results."    This  is  absurd. 

The  third  principle  of  experimentation  is  that  the  results  to  be  of 
most  value  must  be  quantitative.  The  practising  physician  has  hardly 
made  a  beginning  in  the  use  of  this  principle. 

The  Experimental  Sciences 

The  sciences  which  are  preeminently  experimental  are  physics, 
chemistry,  physiology,  pharmacology  and  bacteriology.  Each  of  these, 
like  anatomy,  makes  a  large  demand  for  pure  observation  and  is  valuable 
for  developing  that  power.  In  addition,  each  asks  for  experiment. 
Their  general  principles  are  alike,  but  each  has  a  technic  of  its  own. 
Physics  lends  itself  more  easily  to  the  quantitative  method.  Chemistry 
and  bacteriology  furnish  valuable  aids  to  diagnosis,  but  are  distinctively 
in  vitro  as  to  method.  Physiology  and  pharmacology,  on  account  of 
their  use  of  living  material  for  experimental  purposes,  come  especially 
close  to  medicine,  not  only  in  subject-matter  but  also  in  method. 

What  I  have  said  regarding  observation  and  anatomy  applies  equally 
well  to  experimentation  and  to  the  sciences  Just  mentioned.  If  the 
"  good  doctor  "  should  be  an  experimenter,  surely  as  a  student  he  must 
learn  to  experiment.  Learning  is  by  doing.  He  must  learn  under  those 
who  know  how  to  experiment  and  how  to  teach  that  art.  This  argument 
leads  inevitably  to  the  professional  bacteriologist,  chemist,  physiologist, 
pharmacologist.  Only  that  man  who  is  specially  trained  in  one  of  these 
sciences,  who  has  done  and  is  doing  research  in  it  and  who  is  devoting 
his  whole  time  to  it  can  teach  it  to  the  best  advantage. 

The  same  arguments  as  formerly  made  also  apply  regarding  equip- 
ment and  facilities,  A  chemical  laboratory  with  a  place  and  apparatus 
and  material  for  each  student  and  rooms  and  equipment  for  the  stafE; 
physiological  and  pharmacological  equipment  and  laboratories  for  stu- 


EQUIPMENT    AND    INSTEUCTION  381 

dents  and  staff;  an  animal  house  and  living  material;  technicians  and 
janitors  (again  on  the  basis  that  an  institution  or  factory  or  railroad 
is  unwise  which  compels  a  five-thousand-dollar  man  to  do  the  work  which 
a  five-hundred-dollar  man  can  do  as  well  or  better)  ;  bacteriological 
equipment  including  proper  space,  instruments  and  materials  for  the 
use  of  instructors  and  students;  books  and  periodicals,  and  places  to 
keep  and  use  them, — all  these  must  be  provided  if  the  institution  has  a 
proper  regard  for  its  output,  a  "good  doctor." 

A  "Good  Doctor"  Must  Reach  Accurate  Conclusions 

To  the  powers  of  observation  and  experimentation  the  "  good  doctor  " 
must  add  that  of  sound  conclusion  or  correct  interpretation  or  good 
judgment.  This  means  the  bringing  of  facts  together  and  the  deter- 
mination of  relationships.  It  means  the  recognition  of  cause  and  effect. 
Doubtless  the  psychologist  would  further  subdivide  the  mental  functions 
involved.    But  for  our  purpose  the  above  will  suflSce. 

Now,  it  is  evident  that  you  can  not  make  a  sound  conclusion  without 
the  facts,  and  these  are  gained  by  observation,  with  or  without  experi- 
ment. It  is  equally  evident  that  an  isolated  fact  is  barren  and  dead. 
Facts  are  like  the  cells  of  a  complex  animal,  all  interrelated,  mutually 
affecting  and  affected.  The  hormones  or  internal  secretions  constitute  a 
fitting  metaphor  for  those  relationships  which  the  power  of  correlation 
discovers  between  the  isolated  results  of  observation  and  experiment. 

Training  Value  of  Pathology 

All  scientific  studies  tend  to  develop  this  power  of  interpretative 
judgment,  but  not  all  to  the  same  extent.  The  d}Tiamic  sciences,  such 
as  physiolog}^,  are  more  valuable  than  the  static  sciences  such  as  anatomy. 
But  perhaps  the  best  for  the  purpose,  at  least  so  far  as  the  making  of 
doctors  is  concerned,  is  pathology.  At  any  rate,  I  have  reserved  this 
science  to  illustrate  this  phase  of  my  thought. 

Here  we  have  a  pathological  condition.  The  normal  appearance, 
structure,  relation,  should  be  such  and  such.  It  should  function  so 
and  so.  How  and  why  did  this  change  come  about,  and  what  and  how 
far-reaching  may  be  its  results?  The  entire  keyboard  of  observational 
science,  almost,  may  here  be  played  upon:  Physics,  chemistry,  zoology, 
botany,  anatomy,  histology,  physiology,  bacteriology.  And  just  as  in 
music  the  harmony  or  dissonance  depends  on  how  the  notes  are  chosen 


382  MEDICAL   EESEABCE   AND   EDUCATION 

and  blended,  so  the  soundness  or  unsoundness  of  conclusions  depends  on 
how  well  facts  have  been  determined  and  how  truthfully  their  relations 
have  been  perceived. 

Wholly  apart,  then,  from  the  significant  facts  which  it  presents, — 
in  other  words,  its  subject-matter, — patholog}'  is  justified  in  our  curric- 
ulum on  account  of  the  training  it  affords  in  one  of  the  indispensable 
mental  qualities  of  the  '"'good  doctor."  The  doctor  without  sound 
judgment,  which  means  without  the  power  of  scientific  deduction,  is 
indeed  a  very  had  doctor.  You  catch  again  the  drift  of  my  argument. 
TVe  must  supply  a  professional  pathologist  who  shall  devote  his  best 
efforts,  in  conjunction  with  those  other  scientists  already  mentioned, 
to  building  up  the  students'  mental  machinery  for  orderly  and  logical 
reasoning. 

Just  as  in  the  former  cases,  here  also,  while  the  man  is  of  first  impor- 
tance, he  can  not  do  good  work  without  proper  surroundings  and  proper 
equipment.  You  must  not  only  furnish  the  pathological  laboratory  and 
library,  but  also,  and  more  important,  you  must  secure  such  hospital 
connections  as  will  guarantee  ample  autopsies  and  supplies  of  material 
for  gross  and  microscopic  study.  You  must  give  the  pathologist  proper 
help  for  the  best  conduct  of  his  department.  You  are  not  having  proper 
regard  for  your  "  model "  or  your  output,  the  "  good  doctor,"  if  you  dis- 
regard these  important  matters. 

FUXDAMEXTAL  SCIENCES  SOTJECES  OF  POWEE 

So  far  I  have  considered  three  traits  of  a  properly  trained  medical 
practitioner,  power  of  observation,  ability  to  experiment  and  sound  judg- 
ment. I  have  attempted  to  prove  that  the  fundamental  sciences,  wholly 
apart  from  their  subject-matter,  are  justified  in  the  medical  curriculum 
as  sources  of  power.  I  have  tried  to  show  that  they  must  be  taught  by 
professional  scientists  and  not  by  practising  physicians.  I  have  pointed 
out  that  proper  laboratories  and  equipment  must  be  provided,  and  that 
to  curtail  your  departments  in  material  and  help  is  narrow  business 
policy.  There  are  a  few  practical  conclusions  from  these  premises  which 
I  wish  now  to  present. 

Xeed  of  the  Eeseaech  Peofessoe 

If  the  sciences  are  to  be  taught  for  power  rather  than  subject-matter, 
we  have,  as  I  have  said,  the  unanswerable  argument  for  the  research  pro- 


EQUIPMENT    AND    INSTRUCTION  383 

fessor  in  charge  of  each  scientific  department.  He  alone  thoroughly 
understands  the  scientific  method.  How  absurd,  if  this  is  true,  is  that 
frequent  arrangement  in  which  the  professor  lectures  and  the  untrained 
or  half -trained  assistants  conduct  the  laboratory  work!  Laboratory 
instruction  conducted  from  the  standpoint  of  scientific  method  is  the 
most  difficult  form  of  teaching.  Too  often,  as  Dewey*  well  says,  labora- 
tory practise  becomes  purely  ritualistic;  such  and  such  forms  to  go 
through;  such  and  such  demonstrations  of  manual  dexterity  to  be 
secured.  This  degeneration  of  laboratorj'  teaching  is  due  largely  to  that 
Isixity  and  short-sightedness  which  permit  its  being  turned  over  to 
secondary  instructors.  Better  by  far,  if  either  must  be  done,  is  it  to  have 
the  assistant  give  the  lectures  and  the  professor  the  laboratory  instruc- 
tion, rather  than  the  reverse. 

ESSEXTIAL  LaBOEATOEIES 

Secondly,  I  have  spoken  of  student  laboratories.  A  little  reflection 
shows  that  these  are  of  four  kinds,  each  concerned  with  a  different  mate- 
rial and  provided  with  a  different  type  of  equipment.  The  first  is  con- 
cerned with  the  human  cadaver.  The  equipment  is  simple  and  for  a 
variety  of  reasons  the  rooms  must  be  restricted  to  the  one  use  only.  The 
second  type  of  laboratory  is  adapted  to  chemical  experimentation.  The 
requirements  of  heat,  water,  numerous  reagent  bottles  and  considerable 
individual  equipment,  as  well  as  the  unavoidable  fumes  and  waste  prod- 
ucts, make  it  inadvisable  to  use  this  laboratory  for  any  other  purpose 
than  the  teaching  of  chemistry.  The  third  type  of  laboratory  centers 
around  the  use  of  the  microscope.  Appropriate  tables,  abundant  light, 
and  individual  microscopes  are  indispensable.  The  same  room  may 
serve  for  microscopic  anatomy  and  pathology  and,  with  some  additional 
equipment,  for  bacteriolog}'.  The  fourth  type  of  laboratory  is  adapted 
to  physiologic  experimentation.    It  may  also  be  used  for  pharmacology. 

Good  Teachees  vs.  Fixe  Buildings 

A  medical  school  which  has  four  good  laboratories  for  students'  use 
should  spend  its  superfluous  cash  on  men  rather  than  buildings.  I  have 
no  s}TQpathy  with  that  condition  which  I  recently  saw  in  one  of  our 
great  medical  schools  where  sLx  magnificent  laboratories  are  used  only 
three  mornings  or  three  afternoons  a  week  for  four  months  of  the  year. 

♦  Science,  January  28,  1910,  Vol.  XXXI.,  p.  121. 


384  MEDICAL   BESEABCE   AND    EDUCATION 

I  admit  the  advantages  of  good  architecture  and  fire-proof  construction 
and  modern  ventilation,  but  I  contend  that  in  some  places  depart- 
mental pride  and  too  abundant  funds  have  led  to  a  multiplication  of 
laboratories  which  is  not  justifiable.  That  all  the  ideas  of  industrial 
efficiency  can  not  properly  be  applied  to  universities  is  readily  recog- 
nized, but  every  new  building  means  more  money  for  maintenance  and 
less  for  men.  In  our  line  of  business,  to  use  a  slang  expression,  the 
man  is  the  "whole  works,"  which  is  really  but  another  way  of  saying 
"teacher  at  one  end  of  a  log  and  student  at  the  other,"  One  log  will 
do  for  several  teachers,  if  used  at  different  times  of  the  day  or  different 
days  of  the  week  or  different  months  of  the  year. 

Thirdly,  regarding  equipment,  if  proper  instructors  are  secured,  you 
can  leave  the  details  to  them.  You  remember  the  advertisement  of  the 
house-furnishing  concern,  "  You  get  the  girl,  we  will  do  the  rest."  The 
medical  school  may  well  be  advised  to  get  the  man  and  he  will  do  the 
rest.  Getting  the  man,  too,  is  as  serious  a  matter  for  the  school  as 
getting  the  bride  is  for  the  swain  for  whom  the  advertisement  was 
originally  intended. 

It  was  once  remarked  that,  if  you  give  Jacques  Loeb  a  collar  box  and 
a  piece  of  string,  he  will  make  a  discovery.  On  the  other  hand,  I  know 
a  man  who  three  years  ago  could  not  do  any  work  because  his  Edinger 
apparatus  had  not  come ;  two  years  ago  he  was  waiting  for  material  from 
Java ;  last  year  he  found  he  needed  a  dark  stage  illuminator  and  a  micro- 
polariscope.  Now  he  is  waiting  for  a  new  laboratory  building.  These 
extremes  illustrate  the  man  and  equipment  proposition  better  than 
many  paragraphs  of  theory. 

Teachers  more  Important  than  Equipment 

For  our  friends  the  state  boards  we  may  respectfully  suggest  that 
they  spend  more  time  in  trying  to  find  out  whether  the  medical  schools 
are  properly  manned,  and  less  in  making  lists  of  apparatus  which  may 
or  may  not  be  used.  I  once  tramped  to  the  top  floor  of  our  medical 
college  in  order  to  demonstrate  to  an  inspector  that  we  have  a  perimeter ; 
and  when  I  showed  it  to  him  in  a  ease  with  other  instruments,  I  am 
willing  to  take  oath  that  he  was  either  cross-eyed  or  else  he  looked  at 
the  wrong  thing.  This  same  man  did  not  ask  how  many  paid  professors 
we  have,  nor  what  their  training  and  experience  have  been,  nor  whether 
we  are  doing  any  original  work,  nor  what  the  annual  budget  is.    But  he 


EQUIPMENT    AND    INSTRUCTION  385 

did  inquire  what  we  were  doing  with  those  dogs  in  a  medical  school. 
And  he  did  naively  remark  when  I  showed  him  the  pathological  outfit: 
"  Ah,  your  chemist  is  in  charge  of  this  work  ?" 

Most  humiliating  of  all — but  whether  for  me  or  him  I  know  not — 
was  his  inquiry  after  consulting  his  typewritten  list  whether  we  had  a 
"bakoscope."  I  took  a  glance  at  the  list  to  make  sure  I  had  heard 
rightly.  It  was  there,  "  Bakoscope " ;  and  unwilling  to  admit  that  I 
didn't  know  of  such  an  instrument,  I  regretfully  confessed  that  we  did 
not  have  one.  I  think  the  investigator  took  some  satisfaction  in  noting 
this  fact  on  his  report.  It  was  not  until  some  days  later  that  it  dawned 
upon  me  that  this  probably  should  have  read  "  phakoscope."  But  of 
course  my  native  modesty,  up  to  this  time,  has  prevented  my  informing 
the  gentleman  of  this  supposition.  For  the  information  of  certain 
captious  individuals  I  should,  perhaps,  add  that  the  inspector  in  ques- 
tion was  not  Mr.  Flexner  nor  Dr.  Colwell. 

The  Doctor's  Influence 

Coming  back  now  to  my  main  theme,  it  seems  to  me  that  the 
qualities  of  accurate  observation,  correct  experimentation  and  logical 
conclusion  are  the  ones  which  the  doctor  must  depend  on  for  success  in 
the  practical  part  of  his  profession.  They  are  the  attributes  of  a  good 
technician.  But  the  doctor  is  more  than  a  technician.  He  stands  in 
the  most  intimate  private  relation  to  his  patients.  The  nature  of  his 
work  contributes  to  his  influence  on  the  social  order.  Other  men  in 
their  professional  and  business  life  are  apart  from  society.  Only  in  their 
leisure  hours  are  they  affecting  the  life  of  other  people,  and  then  not 
intimately.  The  doctor's  influence  is  always  being  exerted,  and  is 
always  direct  and  potent. 

The  "  Good  Doctor  "  a  Man  of  Character 

Now,  the  psychological  qualities  bearing  on  this  side  of  the  doctor's 
life  are  many  and  varied.  Professor  Minot''  considers  that  loyalty  is  the 
trait  which  is  most  essential.  But  I  prefer  to  join  all  the  qualities  of 
loyalty,  sympathy,  promptness,  honesty,  discretion,  firmness  and  many 
more  into  the  one  quality — character.  We  are  agreed  that  the  good 
doctor  must  be  a  man  of  character.  Now  character,  like  everything  else, 
.seems  partly  hereditary  and  partly  acquired.     The  hereditary  element, 

•  Journal  American  Medical  Association,  1909,  Vol.  LIII.,  p.  502. 

26 


386  MEDICAL   BESEABCH    AND    EDUCATION 

as  also  the  early  acquired,  concerns  our  raw  material.  We  are  justified 
in  rejecting  and  must  reject  any  applicants  who  give  evidence  of  defect- 
ive character.  That  is,  however,  a  hard  problem  and  not  for  discussion 
to-day.  The  question  here  is,  what  can  we  do  for  the  upbuilding  of 
character  in  the  medical  school?  I  take  it  that  this  is  a  most  serious 
question.  Under  our  control  and  direction  come  a  multitude  of  young 
men,  many  of  them  just  from  their  homes  for  the  first  time  and  all  of 
them  pointed  toward  a  profession  whose  influence  reaches  the  very 
fountains  of  human  life.  We  can  not,  if  we  would,  avoid  responsibility 
for  the  character  of  these  men. 

But  how  can  we  influence  them?  They  are  at  that  age  when  the 
unfettered  soul  dips  into  life  in  all  directions ;  that  age  whose  impelling 
powers  determine  lines  of  progress  for  a  lifetime;  that  age  which 
examines  and  tests  and  questions  all  things  whether  material  or  intel- 
lectual. You  can  not  do  much  with  these  men  by  talk.  A  preacher  in  a 
medical  school  would  need  the  rarest  tact  not  to  be  worse  than  useless. 
I  take  it  that  our  young  men  are  influenced  most  by  those  whom  they 
admire.    These  they  imitate  unconsciously. 

The  Best  Teachek  a  Man  of  Character 

The  point  I  am  driving  at  is  that  your  medical  teacher  must  be  a 
man  of  character.  He  must  be  a  man  to  whom  young  men  will  be 
attracted  and  whom  they  may  safely  imitate.  The  scientific  attitude  of 
mind  with  its  rigid  adherence  to  truth  supplies  a  basic  condition  of 
character;  and  that  is  why  professional  scientists  and  the  scientific 
atmosphere  are  especially  influential  on  the  character  of  medical  stu- 
dents. But  other  things  are  necessary.  I  would  not  have  a  teacher  who 
is  habitually  profane.  Not  merely  because  profanity  is  wicked,  but 
because  it  does  not  conduce  to  the  "good  doctor."  I  would  not  have  a 
man  whose  lectures  are  chiefly  or  even  partially  made  up  of  coarse 
stories.  I  would  not  have  as  an  instructor  in  a  medical  school  a  doctor 
who  all  the  time  emphasizes  the  financial  aspects  of  his  profession. 

My  thesis  is  that  character  is  the  sine  qua  non  of  the  "  good  doctor," 
and  that  the  principal  way  we  can  influence  the  medical  student,  who  is 
a  doctor  in  the  making,  is  by  surrounding  him  with  characters  worthy 
of  imitation.  Consequently,  the  character  of  a  medical  teacher  is  a 
matter  for  the  gravest  consideration.  Unless  you  take  cognizance  of 
this  you  are  not  having  regard  for  your  output,  a  "  good  doctor." 


EQTJIPMENT    AND    INSTEUCTION  387 

Eecapitulation 

To  recapitulate,  we  as  medical  teachers  are  engaged  in  manufac- 
turing. Our  product  is  doctors,  and  they  ought  to  be  "good  doctors." 
A  "good  doctor"  is  a  man  of  character,  who  possesses  the  technical  \ 
qualifications  for  accurate  observation,  properly  conducted  experimenta-  ,^' 
tion  and  sound  interpretation.  For  the  acquisition  of  the  traits  men- 
tioned no  discipline  is  better  than  that  furnished  by  the  fundamental 
medical  sciences.  The  sciences  therefore  should  be  taught  as  method 
rather  than  as  subject  matter. 

"We  must  furnish  for  this  purpose  skilled  professionals;  in  other 
words,  investigators.  We  must  give  them  places  for  work;  that  is, 
laboratories.  We  must  furnish  equipment ;  that  is,  tools  and  books.  We 
must  select  good  raw  material  and  leave  it  in  the  hands  of  the  workmen 
long  enough  to  enable  them  to  produce  good  goods.  If  we  do  not  do 
these  things,  we  are  not  conducting  an  honest  business.  Our  product  is 
a  cheap  and  deceptive  imitation.  Our  graduate  is  a  counterfeit,  and  we 
have  not  even  the  counterfeiter's  excuse  that  we  need  the  money,  for 
there  is  no  longer  any  money  to  be  made  in  medical  education. 


THE   EDUCATIONAL  FUNCTION  OF  HOSPITALS  AND 

THE  HOSPITAL  YEAE^ 

James  B.  Herrick,  A.M.,  M.D., 
Professor  of  Medicine,  Eush  Medical  College,  Chicago 

The  central  figure  in  every  hospital  is,  or  should  be,  the  patient. 
Whatever  use  is  made  of  the  hospital  as  a  means  of  education  it  should 
be  self -understood  that  whenever  the  sick  man  enters  its  walls  he  has  a 
right  to  expect  and  demand  the  most  skilled  treatment  its  staff  can  offer. 
We  physicians  believe  that  the  best  treatment  will  be  in  the  hospital  that 
clearly  recognizes  its  educational  function.  But  if  the  patient  be  utilized 
for  the  instruction  of  nurses,  undergraduate  or  graduate  medical  stu- 
dents, or  in  the  working  out  of  some  scientific  problem,  there  must  be 
assurance  that  his  life  is  not  endangered  thereby  or  his  health  impaired. 
We  may  use  him  as  "  material,"  to  employ  the  word  that  unfortunately 
has  become  fixed  in  our  medical  vernacular,  but  not  as  we  use  a  Wheat- 
stone  bridge,  a  burette,  a  test  tube,  a  guinea-pig  or  rabbit.  We  claim 
that  it  is  our  right  and  duty  to  experiment  with  inanimate  apparatus, 
;and — when  we  are  humane — with  the  lower  animate  bodies,  even  though 
the  test  tube  break  or  the  rabbit  die.  But  a  human  being  is  neither  a 
test  tube  nor  a  guinea-pig.  We  may  study  his  disease,  even  experi- 
mentally, but  we  must  treat  him  as  a  fellow  man. 

A  modern  hospital  fully  awake  to  its  privileges  and  with  the  high 
aim  to  do  the  greatest  possible  amount  of  good  will  strive  to  educate: 
(1)  Undergraduates;  (2)  internes,  graduate  or  undergraduate;  (3) 
resident  physicians  and  surgeons;  (4)  the  attending  staff;  (5)  nurses; 
(6)  research  workers;  (7)  the  patient;  (8)  the  public. 

1.    Undergraduate  Instruction 

Undergraduate  medical  instruction  can  best  be  carried  on  in  a  hos- 
pital founded  primarily  for  educational  purposes,  and  especially  one 
under  the  immediate  control  of  a  medical  school.  The  student's  pres- 
ence in  the  ward  is  not  looked  on  as  an  intrusion  or  as  due  to  favoring 
condescension  on  the  part  of  the  hospital  authorities.     He  is  there  by 

*  Published  in  the  American  Medical  Association  Bulletin,  January  15,  1911. 

888 


TEE    HOSPITAL    YEAR  389 

right ;  he  makes  examinations,  acts  as  clerk  in  recording  changes  in  the 
patient  from  da}'  to  day,  is  laboratory  assistant,  etc.  And  yet  he  is 
without  authority  to  prescribe  for  or  to  treat  the  patient.  He  makes  no 
promiscuous  examinations.  He  is  watched  and  guided  and  does  no 
harm.  He  follows  the  case  during  the  course  of  the  illness.  A  student 
carefully  observing  and  studying  even  a  small  number  of  cases  of  illness, 
even  though  the  maladies  be  simple,  compelled  to  keep  complete  records 
that  are  scrutinized  daily  by  his  superior,  has  learned  more  of  correct 
methods  and  of  practise,  perhaps  more  even  of  fact,  than  from  hours  and 
hours  of  lectures. 

In  the  majority  of  our  public  hospitals  the  lax  methods,  the  multi- 
tude of  students,  the  prejudice  against  the  use  of  the  patient  as 
"material,"  the  politician's  fear  of  criticism,  the  failure  to  provide 
capable  and  responsible  supervision,  make  students'  ward  work  very  un- 
satisfactory or  wholly  impossible.  Much  is  often  accomplished  by  means 
of  small-group  clinics  with  the  student  at  the  bedside  as  the  case  is 
demonstrated,  or  by  ward  walks  as  in  England.  And  much  is  done  by 
the  arena  clinic,  no  longer  popular  as  of  old,  but  by  no  means  entirely 
out  of  date,  and  still  fulfilling  a  useful  though  subordinate  purpose. 

2.     Instructiox  of  Intekxs 

Of  the  value  of  an  internship  in  a  good  hospital,  where  in  addition  to 
the  student's  clerical  and  laboratory  work  there  is  actual  responsibility, 
usually  a  graded  responsibility,  i.  e.,  one  increasing  with  his  length  of 
service,  there  is  no  question.  Xo  one  who  has  had  the  advantage  of  such 
a  training  doubts  its  value;  no  one  who  has  not  had  it  but  regrets  his 
inability  to  secure  it.  The  eager  competition  among  our  raw  graduates 
for  these  positions  shows  the  estimate  placed  upon  them  by  our  student 
body. 

Sooner  or  later  some  period  of  training — say  a  year — in  a  hospital 
should  be  required  of  every  student  before  he  becomes  a  licentiate  in 
medicine.  If  the  time  is  ripe  it  should  be  demanded  now.  We  must 
command  the  support  of  the  public  in  this  advance  by  making  them  see 
that  if  the  young  graduate  does  not  gain  his  practical  experience  in  a 
hospital  under  the  guidance  of  older  heads  and  in  an  atmosphere  redo- 
lent of  traditional  medical  knowledge  handed  down  from  one  generation 
of  interns  to  another  and  from  one  group  of  attending  men  to  another — 
and  this  traditional  knowledge  is  one  of  the  most  valuable  assets  of  a 


390  MEDICAL   BESEABCE   AND    EDUCATION 

hospital — if  he  does  not  get  his  training  in  this  safeguarded  manner 
before  he  is  a  licensed  practitioner  he  is  forced  to  get  it  in  his  private 
practise,  on  your  child  or  on  mine  and  with  no  counseling  voice  of 
senior  to  keep  him  from  sins  of  omission  or  commission. 

The  marvel  is  that  so  many  men  with  utter  lack  of  hospital  training 
are  able  to  go  out  and  do  so  well — i.  e.,  do  so  little  harm.  Native 
shrewdness,  earnest  endeavor,  tact,  ability  to  learn  quickly  from  others 
and  from  their  own  mistakes,  enable  them  to  succeed  in  a  wonderful 
manner.  How  many  sad,  even  fatal,  blunders  are  made  through  lack  of 
proper  practical  training  no  one  can  tell — it  is  best  not  to  tell.  Even 
the  celebrated  Dr.  San  Grado  wished  Gil  Bias  to  go  about  with  him  for 
a  few  days  on  his  rounds  of  bleeding  and  drenching  his  patients  with 
water  before  the  said  Gil  Bias  was  to  be  permitted  to  practise  as  the 
representative  of  San  Grado. 

The  difficulties  in  the  way  of  a  required  fifth  hospital  year  are  not 
insurmountable.  More  internships  must  be  available  to  accommodate 
our  large  annual  output  of  doctors  or  the  number  of  graduates  lessened. 
Why  not  both?  If  the  efforts  made  by  this  association  are  successful 
the  number  of  graduates  in  medicine  will  be  diminished.  But  the  num- 
ber of  hospitals  will  increase;  and  many  small  hospitals  now  working 
without  interns — and  there  are  large  ones,  too,  in  this  same  condition — 
will  see  that  it  is  impossible  to  get  along  satisfactorily  without  these 
assistants  and  so  more  places  will  be  available.  But  there  is  another 
difficulty,  and  to  my  mind  by  no  means  an  insignificant  one.  How  are 
these  hospitals  to  be  standardized  ?  In  general  the  work  of  the  staff  and 
of  the  intern,  in  a  hospital  with  medical  college  affiliation,  is  up  to  the 
standard  of  the  medical  school  itself,  yet  not  always.  The  small  medical 
school  with  the  large  hospital  at  its  command  can  take  care  of  its  own 
graduates  and  place  them  as  interns.  But  what  about  the  large  medical 
school  with  a  small  hospital?  Its  graduates  mvist  be  placed  in  other, 
perhaps  remote,  hospitals.  Now  there  will  have  to  be  a  good  deal  of 
educating  of  some  hospital  boards  of  management  and  of  many  medical 
staffs,  taking  hospitals  as  they  run,  before  we  can  declare  that  an  intern- 
ship in  some  of  these  hospitals  meets  anything  like  satisfactory  require- 
ments. Many  small  hospitals  and  many  large  ones  with  no  medical 
school  attachment  would  readily  be  conceded  as  up  to  grade.  But  in 
many  hospitals,  some  small,  some  large,  some  in  the  small  towns  and 
some  in  the  large  cities,  the  intern  does  little  more  than  give  an  anes- 


TEE    HOSPITAL    YEAR  391 

thetic,  dress  and  take  the  blame  for  the  pus  eases,  and  occasionally 
examine  the  urine  or  sputum.  No  histories  or  none  worthy  the  name, 
no  laboratory  tests,  no  thorough  examination  of  a  patient.  The  intern 
gains  a  certain  amount  of  self-confidence,  often  an  unwarranted  amount 
which  is  largely  absorbed  from  the  staff,  though  there  is  seldom  any 
appreciable  loss  at  the  source  of  supply;  he  learns  not  to  faint  at  the 
sight  of  blood,  learns  the  dose  of  a  good  many  drugs,  some  of  which  he 
might  well  forget,  and  he  learns  that  an  easy,  a  lazy,  substitute  for 
thinking  is  to  do  an  exploratory  laparotomy.  Such  training  is  super- 
ficial, incomplete  and  in  many  respects  pernicious.  The  medical  school 
with  a  high  standard  for  both  entrance  and  graduation  must  pause 
before  committing  itself  to  a  policy  of  a  compulsory  hospital  year  until 
there  is  in  sight  a  sufficient  number  of  places  in  good  hospitals  where 
work  will  be  up  to  grade  and  where  by  virtue  of  authority  to  inspect 
and  supervise  there  may  be  a  guaranty  that  it  will  be  kept  up  to  grade 
and  satisfactory  to  the  college  and  to  the  officials  of  the  state.  Before  a 
compulsory  fifth  year  is  added  to  our  college  requirements  for  gradua- 
tion a  certain  standard  for  hospitals  must  be  fixed  and  means  taken  to 
sustain  the  same. 

3.     Educating  Eesident  Physicians  and  Surgeons 

The  older  I  grow  and  the  more  I  see  of  surgery,  the  more  convinced 
I  am  that  the  mere  holding  of  the  degree  M.D.,  as  at  present  granted, 
ought  not  to  entitle  a  man  to  do  surgical  operations,  at  least  major 
operations.  The  lack  of  manual  dexterity  and  celerity,  the  poor  judg- 
ment as  to  how  much  can  and  ought  to  be  attempted  in  a  given  case,  the 
puttering  and  hesitating  due  to  insufficient  self-confidence  and  to  a  fear 
of  supposed  dangers,  or  the  equally  horrible  condition  of  over-confidence 
and  lack  of  dread,  how  keenly  do  all  these  shortcomings,  the  result  of 
limited  or  no  practical  training,  loom  up  before  us  when  we  contem- 
plate an  operation  to  be  done  on  our  friend  or  some  member  of  our  own 
family  by  one  of  these  poorly  qualified  young  graduates.  No  surgery, 
no  major  surgery  at  least,  no  special  surgery,  until  he  has  tried  it  first 
on  the  dogs !  no  surgery  until  as  assistant,  and  perhaps  resident,  he  has 
for  a  given  time  stood  at  the  left  and  then  at  the  right  hand  of  the 
surgeon  and  has  himself,  with  the  help  of  this  surgeon,  done  operations. 
When  the  good,  honest  family  practitioner  tells  you  he  is  convinced  that 
surgical  treatment  of  appendicitis  is  wrong,  because,  of  his  operative 


392  MEDICAL   BESEABCH   AND   EDUCATION 

cases,  three  out  of  four  died,  including  clean  cases  operated  on  in  the 
interval,  and  says  that  he  shall  return  to  the  medical  treatment  which 
gave  him  better  results,  we  agree  that  it  is  wise  for  him  to  treat  appen- 
dicitis medically.  But  the  smile  that  comes  to  our  faces  as  we  note  the 
delicious  humor  of  his  innocent  condemnation  of  self  as  a  surgeon  is 
turned  to  a  sober  frown  as  we  realize  the  pathos  and  tragedy  of  the 
clean  cases.  Make  surgery  more  of  a  specialty  if  you  will;  let  there  be 
fewer  surgeons  in  a  given  area  if  necessary;  divide  the  fee — openly — if 
necessary;  but  insure  more  expert  work  by  requiring  a  special  hospital 
training  before  the  graver  operations  are  attempted.  Our  hospitals  can 
here  do  a  splendid  educational  work  by  giving  opportunities  to  residents 
and  assistants  working  under  the  responsible  guidance  of  the  older  man. 

4.  Educating  the  Attending  Staff 
Of  the  value  of  the  hospital  experience  to  the  member  of  the  staff 
there  is  little  need  to  speak.  Every  physician  and  surgeon  admits  freely 
that  the  faithful  performance  of  his  hospital  duties  makes  him  a 
broader,  more  careful,  more  skillful  man.  There  is  only  one  point  in 
this  connection  that  I  would  emphasize,  and  that  is  that  those  hospitals 
in  which  there  is  a  distinct  teaching  feature  will  have  the  best  service 
from  the  staff  especially  in  the  case  of  the  poorer  and  charity  patients. 
Nothing  so  arouses  the  physician  to  do  his  best,  to  study  his  patient  so 
thoroughly,  as  the  knowledge  that  that  case  of  illness  has  to  be 
demonstrated  at  short  range  to  a  class  of  keen-eyed  students.  A  few 
bad  blunders  before  a  class  are  all  that  is  necessary  to  make  him  more 
careful  next  time.  And  then  the  rubbing  of  elbows  with  our  colleagues, 
the  activating  influence  as  the  older  man  is  inoculated  with  the  enthu- 
siasm of  the  young  man  of  the  staff,  just  back  from  Europe,  perhaps; 
all  this  is  helpful  and  educational. 

5.     Educating  Nurses 

It  is  not  my  purpose  to  dwell  on  the  function  of  the  hospital  as  a 

training  school  for  nurses.     Its  duty  in  this  respect  is  becoming  more 

generally  recognized  and  the  advantages  that  accrue  to  the  hospital,  the 

patient,  the  physician,  the  public,  are  too  well  known  to  be  repeated  here. 

6.     Educating  Eeseaech  Workers 
The  spirit  of  research  has  reached  many  of  our  hospitals.    Some  have 
been  founded  with  the  primary  object  of  promoting  research  along  medi- 


TEE    HOSPITAL    TEAE  393 

cal  lines.  It  is  to  be  hoped  more  will  be  liberally  endowed  so  that  this 
highest  grade  of  work  may  be  carried  on  with  the  closest  possible  union 
between  laboratories,  as  they  are  commonly  termed,  and  the  wards  that 
are  also  really  laboratories.  "While  it  is  not  possible  that  all  our  hospitals 
should  be  sensu  strictiori  research  hospitals,  while  it  is  not  desirable  that 
they  should  all  be  of  this  character,  there  should  be  more  of  the  spirit  of 
investigation  and  reaching  out  for  new  truth  in  our  existing  hospitals, 
even  those  that  are  utilized  for  the  instruction  of  undergraduates, 
interns,  residents  and  attending  staff.  Unless  the  spirit  of  research  be 
in  such  a  hospital  and  pervade  its  various  staffs,  the  educational  func- 
tion languishes  and  the  hospital  atmosphere  is  stale.  To  be  progressive, 
research  must  be  carried  on.  It  may  be  in  trying  out  methods  advocated 
by  others  or  devising  new  and  better  ones;  it  may  be  along  lines  of 
therapy,  surgical  or  medical;  it  may  be  studying  the  refinements  of 
diagnosis  or  the  natural  history  of  disease,  or  in  the  chemical,  bacteri- 
ologic  or  anatomical  questions  concerned  in  disease ;  it  may  be  searching 
for  results  that  are  of  immediate  practical  application  or  working  on 
problems  in  pure  science  where  no  practical  bearing  is  in  sight,  but 
something  of  this  sort  must  be  carried  on  by  the  hospital  workers  or  a 
hospital  is  not  doing  its  duty  in  furthering  knowledge.  And  I  am  of 
the  opinion  that  our  hospitals  will  be  utilized  more  and  more  for  research 
work  in  sociologic  problems.  There  is  a  rich  field  for  such  investigation 
in  many  of  our  wards. 

7.     Educating  the  Patients 

Much  might  be  said  of  the  help  our  hospitals  may  bring  to  their 
patients  in  teaching  lessons  of  obedience  to  authority,  consideration  for 
and  cooperation  with  one's  neighbors,  etc.  Lessons  of  cleanliness  and  of 
hygiene  are  also  taught,  and  surely  certain  lessons  in  morality  are  incul- 
cated in  ways  as  effective  as  any  pulpit  eloquence.  But  this  is  not  the 
time  or  place  for  discussing  this  topic. 

8.     Educating  the  Public 

Nor  is  this  the  place  to  speak  of  the  opportunity  many  of  our  hospi- 
tals have  of  educating  the  public  as  to  matters  of  personal  and  public 
health.  By  example,  by  class  and  lecture  work,  by  literature,  by  letting 
the  hospital  light  not  be  hidden  under  a  bushel,  such  an  institution  may 
be  a  power  for  good  in  the  community  and  be  the  means  of  combating 


394  MEDICAL   BESEABCH   AND    EDUCATION 

the  effects  of  many  foolish  or  even  harmful  "  isms  "  and  "  pathies  "  that 
are  everywhere  to  be  found. 

SUMMAKY 

To  summarize  these  points  which  have  consciously  been  merely 
touched  on  and  not  dealt  with  exhaustively — an  impossibility  in  a 
twenty-minute  paper: 

It  is  the  privilege  and  duty  of  hospitals  to  extend  their  field  of  use- 
fulness by  opening  their  wards  more  freely  to  undergraduates  in  medi- 
cine, to  elevate  the  standards  of  work  done  by  nurses,  interns,  residents 
and  attending  staff,  to  foster  research.  By  so  doing  they  are  not  harm- 
ing the  patient,  but  are  rather  insuring  him  better  and  more  skilled 
treatment.  They  are  serving  to  enlighten  and  educate  not  only  the 
individual,  but  the  observing  lay  public  as  well,  eager  to  learn  and  to  be 
instructed  in  knowledge  of  medical  matters. 

And  what  concerns  us  as  physicians  looking  to  the  elevation  of  the 
standards  of  medical  education  is  that  so  soon  as  possible  each  medical 
school  should  have  its  own  hospital  where  the  wards  are  freely  utilizable 
for  the  instruction  of  undergraduates,  where  a  definite  service  in  prac- 
tical work  in  medicine  and  surgery  shall  be  demanded  as  a  prerequisite 
for  graduation,  where  assistants  and  residents- may  be  in  training  for 
specialties  in  medicine  and  surgery  and  where  the  spirit  of  investigation 
and  research  pervades  every  worker  from  the  probationer  nurse  to  the 
chief  of  the  attending  staff. 

Until  such  medical  school  hospitals  are  obtained  the  aim  should  be 
to  secure  similar  privileges  in  other  good  hospitals,  seeing  to  it  that 
some  authoritative  supervisional  check  may  be  had  on  the  character 
of  work  that  is  there  done  before  credit  is  given  in  the  medical  school 
for  such  undergraduate  or  intern  hospital  service. 


THE  ADDITION  OF  A  FIFTH  YEAR  TO  THE  MEDICAL 

CUEEICULUM 1 

By  Johx  M.  Dodsox,  M.D., 

Professor  of  Medicine  and  Dean  of  the  Medical  Courses, 
University  of  Chicago 

The  remarkable  advance  in  medical  education  in  the  last  quarter 
century  has  concerned  both  the  kind  and  the  amount  of  the  training 
demanded  of  the  medical  student.  Laboratory  and  practical  courses, 
in  which  the  students,  in  small  groups,  are  brought  into  immediate 
contact  with  the  materials  to  be  studied,  and  thus  obtain  knowledge  at 
first  hand,  have  largely  supplanted  the  didactic  lecture  and  recitation, 
especially  in  the  fundamental  branches.  Unfortunately,  the  introduc- 
tion of  similar  methods — of  objective  teaching — in  the  clinical  subjects 
has  made  little  progress,  excepting  in  a  few  schools,  and  the  lamentable 
deficiency  of  our  medical  students  in  practical  experience  at  the  bedside 
is  keenly  realized.  How  serious  and  deplorable  is  this  deficiency  has 
been  graphically  set  forth  by  Mr.  Flexner,  of  the  Carnegie  Foundation, 
in  his  Eeport  on  Medical  Education. 

The  amount  of  education  demanded  has  been  increased  at  two 
points — the  extent  of  preparation  exacted  for  admission  to  the  medical 
school,  and  the  length  of  time  required  to  be  spent  therein.  As  the  suc- 
cessive steps  in  advance  have  been  taken,  the  decision  as  to  where  the 
increase  should  be  made  has  not  always  been  wise.  When,  for  example, 
about  fifteen  years  ago,  a  general  increase  was  made  in  the  curriculum 
froiii  three  to  four  annual  sessions,  it  would  have  been  better  if,  in  lieu 
of  this,  the  advance  had  been  in  the  premedical  requirement,  this 
requirement  being  at  that  time  in  most  schools,  about  two  years  of 
high-school  work,  rather  loosely  enforced.  Much  more  would  have  been 
accomplished  in  the  direction  of  elevating  the  standards  of  the  medical 
profession  had  the  emphasis  been  placed  at  that  time  on  a  fairly  ade- 
quate preparation  for  medical  study. 

Fortunately,  during  the  last  five  or  six  years,  rapid  progress  has 

^  Eead  before  the  meeting  of  the  Association  of  American  Medical  Colleges, 
Chicago,  February  28,  1912.  Published  in  the  Journal  of  the  American  Medical 
Association,  August  24,  1912. 

395 


396  MEDICAL   BESEAECH   AND   EDUCATION 

been  made  in  this  direction,  and  with  about  thirty  medical  colleges 
now  exacting  two  years  of  college  work  for  admission,  with  five  of  the 
state  boards  of  medical  examiners  demanding  the  same  as  a  prerequisite 
for  licensure,  it  seems  pretty  certain  that  this  will  be  the  uniform 
standard  of  the  medical  schools,  in  the  northern  states  at  least,  within 
the  next  decade.  With  the  present  conditions  in  most  of  the  secondary 
schools,  and  while  so  large  a  proportion  of  students  enter  college  at 
twenty-one  or  older,  and  the  medical  school  at  twenty-four  or  later,  it 
seems  unwise  to  contemplate  any  further  advance  in  the  requirements 
for  admission  to  the  medical  schools,  as  a  universal  standard,  in  the 
near  future.  Nothing  less  than  this,  however,  will  suffice  to  give  the 
student  adequate  preparation  for  the  study  of  medicine  under  existing 
conditions.  One  year  of  college  work  is  not  enough  to  afford  the 
requisite  training  in  English,  mathematics,  physics,  chemistry,  biology 
and  foreign  languages,  notwithstanding  the  fact  that  the  Council  on 
Medical  Education  of  the  American  Medical  Association  has  recom- 
mended such  a  curriculum  of  one  year. 

If  the  premedical  curriculum  may  be  regarded  as  satisfactorily 
determined  for  the  present,  the  next  step  in  advance  in  medical  educa- 
tion, at  once  the  most  needed,  and,  under  the  right  conditions,  the 
most  feasible,  is  the  addition  of  a  fifth  or  prac^;ical  year  to  the  present 
course  of  study,  this  year  to  consist  of  service  as  an  intern  in  a  hospital, 
under  supervision  of  the  faculty  or,  in  exceptional  cases,  for  those  who 
look  forward  to  a  career  of  teaching  and  investigation,  of  advanced  and 
research  work  in  one  or  more  departments  of  the  college.  This  fiith 
year  should  precede  the  conferring  of  the  degree. 

The  feeling  is  universal  among  medical  educators  that  medical  grad- 
uates are  entering  into  practise  with  too  meager  first-hand  knowledge 
of  disease — such  knowledge  as  can  only  be  gained  by  actual  experience, 
at  the  bedside  under  careful  supervision.  In  the  earlier  years  of  medical 
education  in  the  United  States,  such  experience  was  secured  by  an 
apprenticeship  with  a  preceptor.  This,  indeed,  constituted  the  sole 
means  of  preparation  of  a  considerable  proportion  of  medical  practi- 
tioners until  well  after  the  middle  of  the  last  century.  For  the  re- 
mainder, the  one  or  two  sessions  of  medical  lectures,  of  four  or  five 
months  each,  was  the  incidental  rather  than  the  chief  part  of  their 
training.  The  rapid  development  and  growing  importance  of  the 
fundamental  medical  sciences  led  to  a  steady  increase  in  the  amount  of 


TEE   MEDICAL    CUEEICULUM  397 

time  required  of  the  student  in  the  college,  while  the  changing  condi- 
tions and  methods  of  practise  made  it  more  and  more  difiScult  for  the 
preceptor  to  give  his  student-apprentice  effective  instruction,  and  so  his 
function  in  the  training  of  the  student  became  gradually  less,  and  the 
title  of  preceptor  merely  nominal.  The  passing  of  the  preceptor,  and 
of  the  excellent  practical  training  which  the  student  received  at  his 
hands,  was  a  real  loss  in  medical  education,  but  one  which  seems  to 
have  been  inevitable.  Meanwhile  the  opportunities  for  practical  experi- 
ence in  the  hospital  have  enormously  increased.  The  hospital  idea  has 
grown  rapidly.  The  public  is  becoming  educated  to  the  fact  that  the 
hospital  is  the  best  and  most  economical  place  for  the  sick — medical, 
surgical  or  obstetric.  Few  cities  of  15,000  or  more  inhabitants  are 
to-day  without  one  or  more  hospitals. 

I  have  sought  to  ascertain  the  number  of  hospitals  and  of  hospital 
beds  in  the  United  States  which  do,  or  which  should,  admit  internes  and 
afford  them  reasonably  good  opportunities  for  practical  experience.  I 
have  taken  the  following  figures  from  the  American  Medical  Directory, 
third  edition.  The  data  these  supplied  are  not  perfect,  as  many  insti- 
tutions fail  to  report  the  number  of  beds  or  to  indicate  clearly  the  char- 
acter of  the  hospital.  With  the  data  at  hand  the  hospitals  having  twenty 
beds  or  more  may  be  grouped  as  follows : 

1.  Hospitals  associated  with,  and  more  or  less  completely  controlled 
by,  medical  schools ;  of  these  there  are  104,  with  28,365  beds. 

2.  Hospitals  located  in  cities  where  medical  schools  are  situated, 
but  not  at  present  controlled  by  them;  of  these  there  are  645,  with 
73,535  beds. 

3.  Maternity  hospitals,  located,  with  few  exceptions,  in  cities  having 
medical  schools;  71,  with  4,115  beds. 

4.  Hospitals,  public  and  semi-public,  located  in  cities  not  having 
medical  schools;  of  these  there  are  1,381,  with  82,320  beds. 

5.  Public  hospitals  for  the  insane,  of  which  there  are  173,  with  an 
aggregate  of  183,665  patients. 

6.  County  and  state  infirmaries;  267,  with  30,100  beds. 

7.  Private  hospitals  comprising  (a)  those  for  nervous  and  mental 
diseases  of  which  there  are  124,  with  12,285  beds;  and  (6)  those  for 
medical  and  surgical  and  special  disorders  of  which  there  are  90,  with 
4,990  beds. 

8.  Hospitals  for  contagious  diseases;  there  are  59,  with  6,795  beds. 


398  MEDICAL   BESEABCH   AND   EDUCATION 

9.  Hospitals  and  sanatoriums  for  tuberculosis;  of  these  there  are 
266,  with  31,550  beds. 

10.  TJnited  States  marine,  army  and  military  hospitals,  of  which 
there  are  79,  with  a  total  of  8,255  beds. 

Each  one  of  these  institutions,  with  the  exception  of  those  for  the 
insane  and  some  of  the  infirmaries  for  chronic  diseases,  needs  an  intern 
for  every  twenty  or  twenty-five  beds.  Even  with  our  present  excessive 
output  of  medical  graduates  each  year  (at  least  50  per  cent,  in  excess 
of  the  needs  of  the  country),  there  should  be  a  vacant  internship 
awaiting  every  graduate  in  medicine. 

Several  of  the  stronger  medical  schools  report  that  not  only  has 
every  graduate  from  these  schools  for  the  last  four  or  five  years  been 
able  to  secure  an  internship  in  a  good  hospital,  but  the  demand  for  their 
graduates  to  fill  such  positions  has  exceeded  the  supply. 

In  1906,  one  medical  school  added  a  fifth  year  to  its  curriculum, 
made  optional  and  leading  to  a  cum  laude  degree.  Five  other  schools 
have  since  added  a  fifth  year  as  an  optional  addition  to  the  course  of 
study,  and  one,  the  medical  department  of  the  University  of  Minnesota, 
now  requires  this  year  for  graduation.  In  Germany  a  practical  year 
has  recently  been  made  compulsory  and  a  similar  requirement  obtains 
in  some  other  foreign  countries.  The  uniform  adoption  of  a  curriculum 
extending  over  this  hospital  year  is  recommended  by  the  Council  on 
Education  of  the  American  Medical  Association.  Is  it  feasible  ?  If  so 
what  steps  are  necessary  to  put  it  into  operation?  What  regulations 
should  be  prescribed  in  reference  to  it? 

The  plan  is  desirable  and  practical  for  the  school  which  is  prepared 
for  it  and  which  can  secure  the  necessary  hospital  connections  and 
control  to  insure  a  place,  under  the  right  conditions,  for  all  of  its  stu- 
dents during  this  intern  year.  A  serious  mistake  will  be  made,  however, 
by  any  medical  college  which  rushes  into  the  scheme  hurriedly,  just 
because  the  idea  is  "  in  the  air,"  unless  it  is  able  to  meet  these  essentials. 

In  the  first  place,  no  school  should  add  a  compulsory  fifth  year  until 
its  entrance  requirements  have  been  made  equal  to  those  now  demanded 
by  the  conditions  of  the  time  as  exemplified  by  the  twenty-nine  colleges 
now  exacting  two  years  of  college  work  beyond  the  high  school.  One 
year  is  not  sufficient,  and  especially  will  any  attempt  on  the  part  of  the 
detached  medical  school  to  give  instruction  in  the  required  physics, 
chemistry,  biology  and  modern  languages,  be  a  serious  step  backward. 


TEE   MEDICAL    CUBSICULUM  399 

The  necessity  of  securing  the  proper  connection  with  hospitals  in- 
volves the  large  question  of  the  relation  of  the  medical  school  and  the 
hospital — quite  the  most  vital  question  to-day  in  medical  education  in 
the  United  States.  What  should  that  relation  be?  It  goes  without 
saying  that  the  dispensary  and  hospital  constitute  the  laboratories  for 
the  clinical  branches,  as  do  the  dissecting-room  for  anatomy,  the  morgue 
for  pathology,  and  the  laboratories  of  physiology,  biologic  chemistry, 
pharmacology,  histology,  embryology  and  bacteriology  for  these  several 
sciences.  Mr.  Flexner  says  in  his  report,  in  reference  to  control  and 
utilization  of  the  hospital  for  teaching  and  research,  that  the  medical 
school  should  bear  exactly  the  same  relation  to  the  hospital  that  it  bears 
to  these  other  laboratories.  It  is  obvious,  however,  that  there  are  very 
important  differences  from  the  nature  of  the  case.  The  dissecting- 
room,  the  morgue  and  the  other  fundamental  laboratories  serve  exclu- 
sively the  purposes  of  investigation  and  teaching.  There  are  practically 
no  limitations  on  the  use  of  their  materials  for  these  purposes.  The 
hospital  is  primarily  a  place  for  the  care  and  cure  of  the  sick.  What- 
ever other  purposes  it  may  serve,  its  use,  therefore,  must  always  be 
conditioned  on,  and  subordinate  to,  that  one  vital  fact — the  welfare  of 
the  patients.  No  use  of  these  patients  for  any  purpose  can  for  an 
instant  be  tolerated  which  is  in  any  degree  prejudicial  to  their  welfare, 
entails  unnecessary  suffering  or  delays  their  restoration  to  health. 
Moreover,  in  the  long  run,  it  is  in  the  best  interest  of  science,  as  well 
as  humanity,  that  no  patient  should  be  used  as  a  clinical  subject 
against  his  will.  The  use  of  a  pauper  patient  against  his  will  for 
instruction  or  investigation  on  the  theory  that  he,  in  this  way,  makes 
return  for  his  free  treatment,  is  wrong  in  principle  and  pernicious  in 
practise.  On  the  other  hand,  it  is  seldom  difficult  for  the  tactful,  kind 
physician  to  secure  the  consent  of  a  patient,  rich  or  pauper,  to  serve 
as  a  clinical  subject. 

While  the  use  of  the  sick  for  purposes  of  investigation  and  instruc- 
tion must  ever  be  subordinated  to  their  welfare,  when  conducted  under 
suitable  regulations  and  supervision,  such  use  is  not  only  not  inimical 
to  the  patient,  but  decidedly  in  his  best  interest.  The  hospitals  where 
complete  and  accurate  clinical  histories  are  written,  where  thorough 
diagnostic  methods  are  carried  out  by  modern  methods,  in  a  well- 
equipped  pathologic  laboratory,  are,  almost  without  exception,  hospitals 
under  the  control  of  a  high-grade  medical  school  and  in  which  instruc- 


400  MEDICAL   EESEABCH   AND   EDUCATION 

tion  and  research  are  daily  carried  on.    On  this  point  there  is  unanimity 
of  opinion  by  all  who  are  most  competent  to  speak.    Says  Dr.  Keen : 

I  speak  after  an  experience  of  forty  years  as  surgeon  to  a  half-dozen  hos- 
pitals, and  can  confidently  say  that  I  have  never  known  a  single  patient  injured, 
or  his  chances  of  recovery  lessened,  by  such  teaching.  Moreover,  who  will  be 
most  slovenly  and  careless  in  his  duties,  he  who  prescribes  in  the  solitude  of  the 
sick-chamber,  and  operates  with  two  or  three  assistants  only,  or  he  whose  every 
movement  is  watched  by  hundreds  of  eyes  alert  to  detect  any  false  step?  I 
always  feel  at  the  Jefferson  Hospital  as  if  I  were  on  the  run  with  a  pack  of 
lively  dogs  at  my  heels. 

Miss  Barfield,  after  an  ample  experience  as  nurse  and  patient, 
speaks  as  follows: 

As  a  matter  of  fact,  in  a  properly  administered  hospital,  medical  schools 
are  a  protection  to  the  patient  rather  than  otherwise,  for  it  usually  means  that 
the  hospital  is  a  very  live  one.  In  teaching  hospitals  I  think  that,  on  the  whole, 
patients  are  generally  better  nursed,  for  every  one  is  kept  up  to  the  mark, 
including  the  professors. 

And  the  committee  appointed  in  1905  to  inquire  into  the  financial 
relations  between  the  hospitals  and  the  medical  schools  in  London  says : 

We  find  that  the  pressure  of  a  body  of  eager  young  men  watching  the  pro- 
ceedings of  their  teacher  has  a  tendency  to  keep  the  medical  men  on  the  alert 
and  to  counteract  the  effects  of  the  daily  routine  of  their  duties. 

Indeed,  the  hospital  needs  association  with  the  medical  school  quite 
as  much  as  the  college  needs  the  clinical  material  of  the  hospital. 
Hospital  boards  are  beginning  to  realize  this,  and  some  significant 
demonstrations  of  this  awakening  are  of  recent  occurrence.  About 
three  years  ago  the  board  of  directors  of  a  children's  hospital,  which 
had  been  in  existence  several  years,  voluntarily  sought  and  entered  into 
affiliation  with  the  faculty  of  a  medical  school  which  had  for  several 
years  controlled  another  hospital  to  the  mutual  satisfaction  and  advan- 
tage of  all  concerned.  The  board  asked  the  faculty  of  the  college  to 
assume  entire  responsibility  for  the  medical  conduct  of  the  hospital; 
the  existing  medical  staff  resigned,  and  the  faculty  was  given  full  power 
to  nominate  a  new  staff,  which,  by  the  special  request  of  the  board,  was 
to  include  no  physician  who  was  not  a  member  of  the  faculty;  clinical 
instruction  and  research  to  be  conducted  in  the  wards  as  directed  by 
the  faculty.  Within  a  year  another  institution  has  voluntarily  sought 
and  secured  a  similar  relation  to  the  same  college.  These  facts  are,  to 
my  mind,  a  pretty  certain  indication  of  the  trend  of  the  times  in  refer- 
ence to  the  relation  of  existing  hospitals  and  medical  schoola  in  some  of 


A.i.  REiEARCn 


THE   MEDICAL    CUBBICULUM  401 

the  cities  of  the  United  States.  And  does  it  not  offer  a  more  satis- 
factory and  feasible  solution  of  the  needs  of  the  medical  school  for 
clinical  material  than  does  the  proposition  that  the  medical  school  must 
own  and  maintain  its  own  hospital? 

The  hospital  being  primarily  an  institution  for  the  care  and  cure 
of  the  sick,  its  maintenance  is  not  properly  a  function  of  the  medical 
school,  whose  business  is  specifically  educational — including  research. 
In  most  instances  the  medical  school  has  come  into  existence  to  find 
the  surroimding  community  already  abundantly  supplied  with  hospitals 
— ^the  evidence  of  which  is  furnished  by  the  fact  that  these  hospitals  are 
much  of  the  time  clamoring  for  patients  to  fill  empty  beds.  True,  the 
conditions  in  these  institutions  are  usually  far  from  satisfactory,  but 
even  so  shall  the  medical  college  duplicate  hospital  accommodations 
already  equal  to  or  in  excess  of  the  demands  of  the  community,  at 
enormous  expense  for  construction  and  endowment,  or  shall  it  seek  to 
establish  the  right  relations,  and  secure  the  necessary  control  of  exist- 
ing institutions,  which  control,  as  has  been  pointed  out,  would  be  to  the 
great  advantage  of  both  hospital  and  school  ?  The  great  medical  schools 
of  European  countries,  where  the  control  of  clinical  material  is  most 
satisfactory  and  where  the  best  scientific  work  has  been  done,  do  not  as 
a  rule  own  and  maintain  hospitals.  They  use  the  great  municipal  or 
state  hospitals  maintained  by  the  city  or  state.  The  corresponding 
hospitals  in  our  own  country,  the  management  of  which,  tainted  by 
ward  politics,  has  been  up  to  the  present  time  so  unsatisfactory  from 
every  point  of  view,  nevertheless  contain,  and  will  continue  to  command, 
the  best  possible  clinical  material,  such  as  no  non-public  institution  can 
hope  to  duplicate. 

In  those  rare  instances  in  which  a  large  provision  has  been  made 
for  research,  either  in  the  medical  school  or  in  an  institution  devoted 
solely  to  scientific  investigation,  there  is  advantage  in  having  a  rela- 
tively small  hospital,  liberally  endowed,  in  which  can  be  collected 
groups  of  cases  of  this  or  that  disease,  primarily  for  the  purpose  of  an 
exhaustive  and  protracted  study.  Into  such  institutions  patients  enter 
with  the  express  understanding  that  they  are  to  be  made  the  subjects  of 
investigation — not,  of  course,  to  their  detriment.  Here  the  purpose  of 
investigation  supplants  the  care  and  cure  of  the  sick  as  the  primary 
motive,  and  the  burden  of  maintenance  falls  properly  on  the  endow- 
ment for  research. 
27 


402  MEDICAL   BESEAECH   AND   EDUCATION 

It  seems  to  me,  therefore,  that  even  for  the  purpose  of  securing 
clinical  material  for  the  necessary  instruction  in  the  junior  and  senior 
years  of  the  present  curriculum,  the  medical  school,  with  rare  except 
tions,  must  find  it  through  affiliation  with  existing  or  to-be-established 
hospitals,  on  a  pecuniary  foundation  distinct  from  that  of  the  medical 
school  itself,  and  with  persistent  and  intelligent  effort,  I  believe,  this 
can  be  done.  When  it  comes  to  the  question  of  finding  places  for  all 
of  its  students  in  their  fifth  or  intern  year,  there  can  be  no  question 
about  which  course  the  college  must  pursue.  No  one,  surely,  would 
contemplate  the  possibility  of  a  medical  college  undertaking  the  owner- 
ship and  maintenance  of  a  hospital  of  such  magnitude  as  to  supply 
internships  to  all  of  its  graduates.  To  supply  places  for  all  of  its  stu- 
dents the  students  must  find  places  as  they  are  now  doing,  in  detached 
hospitals,  in  the  cities  where  the  colleges  are  located,  as  well  as  in  other 
cities,  more  or  less  distantly  removed  from  the  medical  schools.  It  is 
of  course  not  possible,  nor  is  it  necessary,  that  the  medical  school  should 
have  the  same  degree  of  control  over  the  hospital  for  this  purpose  as  is 
indispensable  for  the  clinical  work  of  the  earlier  years,  and  for  the 
conduct  of  research  by  faculty  and  students.  Certain  things  it  must 
insist  on,  however,  if  this  fifth  year  is  to  be  of  the  largest  possible  value 
to  the  student.  The  mere  securing  of  an  internship  in  a  nondescript 
hospital,  in  the  perfunctory  manner  in  which  it  is  so  often  done,  does 
not  suffice. 

The  hospital  must  have  or,  not  having,  must  institute  a  good  system 
of  clinical  records  that  the  intern  may  write  accurate  and  thorough 
case  histories. 

It  must  have  a  well-equipped  clinical  laboratory  convenient  to  the 
wards  where  he  may  make  the  necessary  examinations  of  urine,  blood, 
sputum,  etc.,  examine  blood  cultures,  and  carry  out,  in  short,  all  of  the 
approved  modern  methods  of  laboratory  diagnosis. 

Some  one  or  more  members  of  the  staff  must  be  able  and  willing  to 
supervise  closely  the  work  of  the  intern,  correct  his  mistakes,  and  give 
him  needed  instruction  in  the  details  of  the  practise  of  medicine  which 
he  has  not  yet  mastered.  These  members  of  the  staff  will  cooperate 
most  cordially  and  effectively  with  the  faculty  if  they  are  made  extra- 
mural members  of  the  faculty  of  the  school.  They  should  attend  faculty 
meetings  as  often  as  possible,  and  should  feel  themselves  to  be  an  organic 
part  of  the  teaching  body. 


TEE   MEDICAL   CUEHICULUM  403 

It  will,  of  course,  be  of  great  advantage  if  the  hospital  has  a  school 
for  nurses,  and  conducts  the  nursing  work  of  the  institution  along  ap- 
proved modern  lines.  It  will  greatly  enhance  the  quality  of  the  serv- 
ice rendered  by  the  hospital  to  its  interns,  and  not  less  to  its  patients, 
if  it  has  a  trained,  salaried  pathologist  who  gives  all  or  most  of  his  time 
to  the  work  of  the  hospital,  and  who  is  doing  original  investigation  as 
are  other  members  of  the  staff.  In  time  all  of  these  things  must  be 
insisted  on,  but  for  the  present  trained  nursing  and  research  work  are 
unknown  in  so  many  otherwise  acceptable  hospitals  that  their  general 
introduction  may  be  secured  only  in  the  course  of  time. 

The  regulations  prescribed  by  the  faculty  for  the  intern  should  be 
such  as  to  insure  that  this  hospital  year  be  of  the  largest  possible  edu- 
cational value  to  the  student.  The  rules  drawn  up  by  the  faculty  of 
Eush  Medical  College  in  1905  were  set  forth  in  a  circular  announcing 
the  installation  of  the  fifth  year  leading  to  the  cum  laude  degree.  As 
this  announcement  may  not  be  without  interest  in  this  connection  I 

quote  it  in  full. 

Fifth  Year 

Beginning  with  the  sessions  of  1905-6  a  fifth  year  is  added  to  the  cur- 
riculum, which,  for  the  present,  will  be  optional.  The  work  of  this  year  will  be 
that  of 

A.  Graduate  work  in  one  of  the  departments  of  the  college;  or 

B.  An  internship  in  a  hospital. 

On  the  successful  completion  of  this  fifth  year  he  will  receive  the  degree  of 
doctor  of  medicine  cum  laude. 

A.  The  year  of  graduate  work  may  be  taken  either 

1.  In  a  fellowship,  by  students  who  may  be  appointed  to  such  positions;  or 

2.  As  a  graduate  student. 

In  either  case  the  candidate  must  be  in  residence  at  least  three  quarters  and 
complete  the  equivalent  of  seven  majors  of  work  in  some  one  department,  or  of 
nine  majors  in  three  or  more  departments,  and  present  a  satisfactory  thesis. 
The  candidate  most  be  recommended  to  the  faculty  as  entitled  to  the  degree  by 
the  department  in  which  the  graduate  work  has  been  done. 

B.  Fifth  year  in  an  internship. 

Candidate 

1.  Every  student  wishing  to  take  the  fifth  year  as  an  intern  shall  announce 
his  intention  in  writing  to  the  dean  of  medical  students  before  the  last  term  of 
the  quarter  in  which  he  expects  to  graduate. 

2.  The  internship  may  be  procured  by  competitive  examination  or  by  ap- 
pointment. 

3.  Each  candidate  shall,  during  his  service,  be  under  the  frequent  and  close 
supervision  of  a  member  of  the  faculty,  to  be  designated  as  hereinafter  provided. 

4.  He  shall  make  report  to  this  supervising  member  of  the  work  he  is  doing, 


404  MEDICAL   BESEABCE   AND   EDUCATION 

at  least  once  a  month.  Such  report  shall  state  the  number  and  nature  of  the 
eases  he  has  had  under  his  care  during  the  month,  and  the  number  of  days  (if 
any)  that  he  has  been  absent  from  his  work,  and  for  what  cause. 

5.  At  the  end  of  his  year  of  service  he  shall  submit  to  his  faculty  supervisor 
copies  of  the  complete  original  histories  of  at  least  ten  of  the  cases  that  have 
been  under  his  care,  and  which  were  written  by  him,  the  patients '  names  to  be 
omitted.  These  shall  be  submitted  to  the  committee  of  examinations  for  the 
cum  laude  degree. 

6.  At  the  end  of  his  term  of  service  either  (o)  he  shall  present  a  type- 
written thesis  embodying  the  thorough  study  of  a  case  or  group  of  cases, 
including  their  thorough  examination  by  modern  clinical  tests,  which  must  be 
satisfactory  to  the  committee;  or  (b)  he  shall  pass  an  oral  and  practical  exam- 
ination before  the  committee  at  a  time  and  place  to  be  designated  by  the 
committee. 

7.  He  shall  be  present  at  the  commencement  when  the  degree  is  conferred y 
no  degree  is  conferred  in  absentia. 

Faculty  Supervision 

1.  During  the  winter  quarter  of  each  year  the  president  of  the  university,  the 
dean  of  the  faculty  and  the  dean  of  students,  as  a  committee,  shall  designate 

(A)  A  committee  on  examination  for  the  ciim  laude  degree  consisting  of 
five  of  the  faculty  members,  selected  from  at  least  five  of  the  clinical  depart-^ 
ments  (medicine,  surgery  and  obstetrics  to  be  always  represented),  who  shall 
serve  for  the  college  year,  beginning  with  the  succeeding  summer  quarter;  andi 

(B)  Such  a  number  of  supervisors  as  can  most  conveniently  take  charge  of 
the  work  of  the  candidates  for  the  ensuing  year,  for  the  cum  laude  degree  by 
internships.    No  faculty  supervisor  shall  have  charge  of  more  than  five  candidates. 

2.  The  interns  to  be  thus  supervised  shall  be  assigned  to  the  faculty  super- 
visors by  the  committee  on  examinations  for  the  cum  laude  degree,  as  above 
provided  for. 

3.  It  shall  be  the  duty  of  the  faculty  supervisor: 

(A)  To  direct  and  advise  the  interns  under  his  charge  as  to  the  conduct  of 
their  work,  to  the  end  that  it  may  be  of  the  greatest  possible  educational  value 
to  him  or  them.  Such  advice  must  be  so  given  as  in  no  way  to  conflict  with  the 
desires  and  authority  of  the  staff  of  the  hospital  in  which  the  intern  is  serving. 

(B)  He  shall  receive  from  the  intern  a  monthly  report  of  his  work. 

(C)  He  shall  visit,  in  person,  the  hospital  or  hospitals  in  which  the  candi- 
dates under  his  supervision  are  serving,  and  acquaint  himself  thoroughly  with 
the  physicians  of  the  staff  (especially  as  to  their  ability  and  efficiency),  with  the 
equipment  and  the  character  of  its  service. 

(D)  Before  the  close  of  the  year  he  shall,  with  the  approval  and  consent  of 
the  staff  of  the  hospital,  select  from  the  history-sheets  written  in  regular  daily 
routine  by  the  candidates  under  his  charge,  twenty  histories  taken  at  random, 
and  shall  examine  the  same  carefully. 

(E)  He  shall  make  inquiry  of  the  attending  staff  as  to  whether  or  not  the 
service  of  the  intern  has  been  satisfactory,  and  make  a  report  to  the  committee 
when  the  candidate  under  his  charge  has  completed  the  necessary  period  of 
service,  as  to  the  manner  in  which  he  performed  his  duties — whether  satisfac- 
torily or  otherwise — accompanied  by  his  recommendation  as  to  whether  or  not 
the  candidate  should  be  given  the  cum  laude  degree. 


TEE   MEDICAL   CUREICULUM  405 

Hospitals 

1.  The  hospitals  in  which  service  as  an  intern  may  be  considered  acceptable 
for  the  cum  laude  degree  shall  be  selected  by  the  committee  on  relations  with 
other  institutions,  and  be  approved  by  the  faculty. 

2.  Such  hospitals  shall  have  at  least  twenty  beds. 

3.  The  officials  of  the  hospital  shall  be  notified  that  such  and  such  persons, 
whom  they  have  selected  as  interns,  are  to  perform  their  services  also  as  candi- 
dates for  the  cum  laude  degree,  and  the  assent  of  the  officials  to  the  arrangement 
must  be  secured  before  the  service  is  entered  on. 

4.  There  must  be  on  the  staff  of  such  hospital  at  least  one  physician  who  is 
a  member  of  the  faculty  of  Bush  Medical  College — either  intra-  or  extra-mural — 
unless  exception  be  made  by  the  vote  of  the  faculty. 

5.  A  list  of  the  hospitals  approved  by  the  faculty  shall  be  kept  in  the  hands 
of  the  deans  who  will  advise  inquiring  students  whether  any  particular  hospital 
is  or  is  not  included  in  the  list. 

The  requirements  imposed  by  these  rules  were  not  unreasonable  for 
a  cum  laude  degree  which,  it  was  planned,  should  be  the  equivalent  of 
the  master's  degree  (A.M.,  or  M.S.),  conferred  by  a  college  or  univer- 
sity for  one  year  of  graduate  work.  I  am  inclined  to  think  that  they 
are  somewhat  too  rigid  an  exaction,  at  least  in  the  beginning,  for  a 
fifth  year  which  is  made  a  prerequisite  for  the  degree  of  M.D.,  and, 
therefore,  for  licensure  to  practise  medicine.  The  amount  of  routine 
work  now  demanded  of  the  intern  in  many  hospitals  so  consumes  his 
time  as  to  make  it  very  diflScult  and  often  impossible  for  any  but  the 
exceptional  student  to  prepare  a  thesis.  This  ought  not,  however,  so  to 
be.  The  intern  should  have  time  to  study  the  cases  assigned  to  him 
thoroughly  and  carefully,  and  also  pursue  exhaustively  the  study  of 
some  disease  or  condition  as  presented  by  some  interesting  case,  or 
group  of  cases,  to  explore  the  literature  relating  to  that  topic,  and  to 
set  down  in  orderly  fashion  the  results  of  his  investigation.  No  instruc- 
tion or  experience  in  his  career  as  a  student  of  medicine  is  so  potent  an 
educational  measure  as  this  one  of  independent  creative  work.  As  pre- 
viously indicated,  I  believe  it  is  possible  to  extend  this  plan  of  coopera- 
tion and  affiliation  to  hospitals  located  in  cities  more  or  less  remote 
from  the  medical  school.  In  such  case,  also,  the  members  of  the  hospital 
staffs  selected  to  supervise  the  work  of  the  intern  should  be  made  extra- 
mural members  of  the  faculty  of  the  school.  Needless  to  say,  no  such 
appointments  should  be  made  of  physicians  simply  because  they  are 
members  of  the  staff  of  the  hospital.  They  must  be  carefully  chosen 
because  of  their  known  ability  and  willingness  to  instruct  the  student, 
and  to  direct  his  work  carefully,  and  no  hospital  should  be  affiliated 


406  MEDICAL   MESEABCR   AND   EDUCATION 

unless  there  are  such  persons  on  its  medical  staff.  In  most  of  the 
smaller  cities  such  men  are  to  be  found,  fundamentally  as  capable  of 
high-grade  work,  in  practise,  teaching  and  research,  as  are  many  of  the 
members  of  the  intra-mural  faculty.  These  men  would  find,  in  an 
intimate,  vital  connection  with  the  medical  school  and  in  the  work  of 
instructing  students,  an  inspiration  and  stimulus  that  would  be  to  their 
advantage  and  that  they  would  keenly  appreciate.  They  should  visit 
the  medical  school  from  time  to  time,  attend  an  occasional  faculty  meet- 
ing and  become  acquainted  with  its  ideals  and  methods.  Their  connec- 
tion with  the  school  should  be  recognized  by  the  appearance  of  their 
names  and  titles  in  its  bulletins  or  announcements. 

There  is  no  inherent  difiiculty  in  the  plan  of  having  two  or  three 
schools  associated  with  the  same  hospital,  interns  from  each  working 
side  by  side,  as  they  do  at  present  in  some  of  the  larger  hospitals,  each 
intern  under  the  supervision  of  some  member  of  the  staff  who  owes 
allegiance  to  the  school  from  which  the  intern  comes,  and  from  which  he 
is  to  receive  his  degree.  Indeed,  there  are  important  advantages  in 
having  interns  from  two  or  more  schools  working  side  by  side  in  the 
same  hospital,  with  a  common  purpose,  but  stimulating  and  broaden- 
ing each  other's  views  and  knowledge  by  the  diversity  of  their  previous 
education. 

In  these  hospitals  students  in  the  earlier  stages  of  the  medical 
curriculum — that  is,  in  the  long  vacations  succeeding  the  sophomore 
and  junior  years — could,  with  advantage  to  the  hospital,  as  well  as  to 
themselves,  serve  as  externs,  performing  the  simpler  duties  in  the  wards 
and  laboratories  under  the  supervision  of  the  staff  and  the  older  interns. 
These  long,  four  to  six  months'  vacations,  under  the  custom  which  has 
prevailed  since  the  preceptor  became  obsolete,  are  a  sad  waste  of  time 
and  inertia.  Under  the  four-quarter  system  in  Eush  Medical  College, 
the  students  may,  if  they  choose,  continue  in  residence  about  ten  and 
one  half  months  each  year.  In  my  observation  of  many  students  who 
have  pursued  this  plan  during  the  last  twelve  years,  I  have  yet  to  learn 
of  one  who  has  been  harmed  physically,  or  otherwise,  by  continuous 
work  during  the  four  quarters  of  one  or  more  years  of  his  course  of 
study. 

The  division  of  expense  between  the  hospitals  and  any  college  with 
which  it  is  affiliated  should  not  be  difficult  of  adjustment.  The  hos- 
pital, as  a  place  for  the  care  and  cure  of  the  sick,  should  bear  the  expense 


THE   MEDICAL   CUEBICULUM  407 

of  its  maintenance  for  that  purpose.  The  medical  school,  as  an  educa- 
tional institution,  must  meet  any  additional  expense  entailed  by  the 
use  of  the  patients  for  teaching  or  research,  over  and  above  that  which 
would  be  required  to  give  the  best  possible  service  to  the  patient  in  the 
effort  to  restore  him  to  health.  By  no  sort  of  logical  reasoning  can  it 
be  concluded  that  it  is  a  just  obligation  of  the  college  to  pay  for  free 
beds  because  the  patients  occupying  them  are  used  for  clinical  demon- 
stration. It  is  the  function  of  a  charitable  hospital  to  maintain  as  many 
free  beds — free  wholly,  or  in  part— as  its  income  will  permit.  The 
hospital,  as  an  institution,  is  entitled  to  credit  for  benevolence  just  in 
proportion  to  the  amount  which  it  expends  on  the  hospital  care  of  its 
patients  over  and  above  that  which  they  pay  for  such  service.  Credit 
for  free  medical  service  rendered  belongs  to  the  medical  staff  of  the 
hospital  and  to  the  college  furnishing  the  staff — not  to  the  hospital  as 
such.  The  staff  should  utilize  as  clinical  material  any  and  every 
patient  in  the  hospital,  be  he  pauper  or  pay  patient,  who  does  not  object 
to  being  so  utilized.  Of  course  the  interests  of  the  medical  school  and 
every  affiliated  hospital  are  mutual;  both  are  engaged  in  rendering 
service  to  the  sick,  and  each  should  assist  the  other  in  friendly  coopera- 
tion to  secure  the  necessary  endowments  to  carry  on  their  work. 

I  am  not  unmindful  of  the  difficulties  to  be  encountered  in  securing 
the  effective  cooperation  of  hospitals  and  medical  schools,  along  the  lines 
sugggested.  Local  jealousies  among  practitioners,  keen  rivalry  between 
neighboring  medical  schools,  parsimonious  economy  on  the  part  of 
hospital  boards,  "ward  politics"  which  dominate  the  control  of  many 
public  hospitals,  the  lack  of  adequate  endowment  for  both  medical  school 
and  hospital — these  and  other  hindrances  to  good  work  by  both  groups 
of  institutions  and,  therefore,  to  effective  cooperation,  must  be  met  and 
overcome. 

It  is  because  of  the  magnitude  of  these  difficulties  that  great  care 
and  deliberation  are  necessary  on  the  part  of  any  medical  school  which 
proposes  to  make  a  fifth  or  intern  year  a  compulsory  addition  to  its 
curriculum.  The  diploma  issued  by  any  medical  school  should  stand 
for  thorough,  careful  education  at  every  stage  of  the  required  course  of 
study,  and  it  should  not  be  made  to  cover  a  fifth  or  intern  year  until 
the  school  can  give  to  the  student  and  to  the  world  assurance  of  the 
same  effective  instruction,  closely  supervised  under  proper  conditions, 
during  this  fifth  year  that  is  given  during  the  preceding  years  of  the 
curriculum. 


MEDICINE   AND    SOCIOLOGY^ 

By  C.  E.  Bardeen,  M.D., 

Professor  of  Anatomy  and  Dean  op  the  Medical  School, 
XjNivERsiTy  OF  "Wisconsin 

It  is  a  pleasure  to  have  this  opportunity  to  be  with  you  at  your 
commencement  exercises.  Rush  has  attracted  many  Wisconsin  grad- 
uates medically  inclined.  Not  only  in  the  present  graduating  class 
but  also  among  the  members  of  your  faculty  I  greet  not  a  few  Wisconsin 
men.  Furthermore,  the  University  of  Chicago,  with  which  Eush  is 
officially  affiliated,  has  a  course  in  the  premedical  and  medical  sciences 
similar  in  ideals  to  the  one  we  have  at  Wisconsin.  In  the  premedical 
course  at  Chicago  in  addition  to  physics,  chemistry,  biology  and  a 
modern  language  some  work  is  required  in  social  science.  Work  of 
this  kind  is  advised  but  not  required  at  Wisconsin,  but  I  am  not  sure 
but  that  it  should  be  required  there.  There  is  ever  greater  need  for 
sociology  in  medicine. 

On  the  one  hand,  medical  problems  are  at  bottom  social  problems 
and  are  to  be  wisely  solved  only  by  those  who  have  some  knowledge  of 
social  science.  On  the  other  hand,  the  increasing  complexity  of  the 
social  organization  brought  about  by  the  introduction  of  machinery  and 
of  rapid  means  of  transportation  of  people,  materials  and  news,  the 
urbanization  of  the  population  and  industrial  concentration,  have 
developed  social  problems  which  demand  above  all  else  the  intelligence 
of  men  broadly  trained  in  medicine.  The  triumphs  of  civilization  are 
due  to  organization,  to  the  subordination  of  individual  whims  to  broad 
social  aims.  Its  failings,  on  the  other  hand,  are  in  large  part  due  to 
the  too  constant  appeal  to  selfish  personal  interests  as  an  inducement  to 
social  effort.  Much  that  is  weak  and  inefficient  in  the  treatment  of 
disease  by  physicians  is  due  to  a  too  narrow  preliminary  training,  to  a 
too  restricted  attitude,  to  a  selfish,  competitive,  unprogressive  individ- 
ualism, archaic  and  out  of  place  in  modern  highly  organized  society. 
Many  of  the  worst  evils  of  our  present-day  civilization,  dirt,  ill  health, 

*  Address  delivered  at  the  commencement  exercises  of  Rush  Medical  College, 
June,  1911.    Published  in  Science,  October  20,  1911. 

408 


MEDICINE   AND    SOCIOLOGY  409 

despondency,  pauperism  and  crime,  are  in  large  part  due  to  the  failure 
on  the  part  of  the  majority  of  those  trained  in  medicine  to  act  as 
leaders  and  public  educators.  Health  of  body  and  of  mind  should  be 
recognized  as  of  first  importance  to  the  community.  "  They  have  been 
so  recognized,  so  far  as  they  have  been  understood,"  says  Havelock 
Ellis,  "  in  every  great  period  of  civilization  of  which  we  have  much 
knowledge,  as  Roman  and  Moorish  ruins  alone  suffice  to  testify.  That 
they  are  not  so  recognized  to-day  is  the  chief  element  of  rottenness  in 
our  civilization.  We  postpone  laying  the  foundations  of  our  social 
structure  in  order  to  elaborate  its  pinnacles.  "We  have  not  yet  learned 
that  a  great  civilization  is  ill  built  up  on  the  bodies  of  men  and  women 
enfeebled  and  distorted  by  overwork,  filth  and  disease."^ 

The  marvelous  advance  in  industrial  productivity  characteristic  of 
the  past  century  is  due,  on  the  one  hand,  to  the  ideal  of  learning  all 
that  is  possible  about  nature  by  observation  and  experiment,  in  a  word 
to  scientific  research,  and,  on  the  other  hand,  to  the  organized  applica- 
tion of  this  knowledge  to  human  needs.  It  seems  not  improbable  that 
during  the  coming  century  an  equally  earnest  efEort  will  be  made  to 
learn  the  truth  about  mankind,  by  observation  and  experiment,  in  order 
that  the  application  of  knowledge  to  human  needs  may  be  made  more 
efficient.  Medicine  as  a  science  occupies  a  unique  position  in  that,  on 
the  one  hand,  it  is  closely  bound  up  with  the  physical  sciences  on  which 
industrial  productivity  depends,  with  physics,  chemistry  and  biology, 
while,  on  the  other  hand,  it  deals  directly  with  people  in  their  social 
relations  and  is  therefore  intimately  related  to  sociology.  This  latter 
relation  has  not  been  sufficiently  recognized  hitherto  by  either  medical 
men  or  sociologists.  With  the  application  of  a  scientific  sociology  to 
the  needs  of  mankind  the  importance  of  medical  science  will  come  more 
and  more  to  the  fore. 

About  fifty  years  ago  a  witty  Englishman  said  that  the  ancients  had 
tried  to  make  of  medicine  a  science  and  had  failed,  the  moderns  had 
made  of  it  a  trade  and  had  succeeded.  There  is  truth  in  the  statement. 
The  medicine  of  the  ancients  was  rather  an  art  than  a  science.  Empir- 
ical practise  was  ahead  of  the  theories  used  to  explain  the  nature  of 
disease  and  its  treatment.  Medicine  is  still  too  frequently  looked  at 
from  the  standpoint  of  a  trade,  but  since  the  Englishman  gave  his 
cynical  opinion  medicine  has  progressed  as  a  science  more  than  in  all 
the  centuries  before. 

^"'The  Naturalization  of  Health,"  1892. 


410  MEDICAL   BESEABCH   AND   EDUCATION 

In  the  development  of  medicine  four  stages  may  be  recognized,  a 
demonic,  a  hygienic,  a  physiologic  and  an  etiologic. 

In  demonic  medicine  disease  is  looked  upon  as  an  evil  spirit  which 
has  taken  possession  of  the  body  and  which  may  be  scared  out  by  elab- 
orate ceremonies  usually  accompanied  by  noise  and  supposedly  fearful- 
looking  objects.  This  type  of  medicine  is  found  in  practically  all 
savage  tribes  and  wide-spread  even  in  semi-civilized  countries  like  China 
and  India  and  is  not  unknown  in  a  less  crude  form  in  modern  America. 

In  hygienic  medicine  disease  is  looked  upon  as  an  abnormal  func- 
tioning of  the  body  which  can  in  large  part  be  overcome  by  methods 
useful  in  keeping  the  body  in  healthful  activity,  by  regulation  of  the 
diet,  sleep,  air,  bathing,  exercise  and  mental  recreation.  This  type  of 
medicine  was  brought  to  a  high  stage  of  development  by  the  Greeks, 
among  whom  personal  hygiene  was  practised  to  a  degree  of  perfection 
which  it  has  never  elsewhere  reached.  To  Hippocrates  are  ascribed  the 
works  in  which  the  hygienic  medicine  of  the  Greeks  is  summarized.  It 
has  formed  the  basis  of  much  of  the  best  medical  practise  ever  since. 
If,  however,  as  some  historians  believe,  the  decline  of  Greece  was  due  in 
large  part  to  malaria,  the  Greeks  in  the  end  served  to  illustrate  the 
inadequacy  of  merely  hygienic  medicine. 

Physiologic  medicine  is  based  upon  centuries  of  study  of  the  struc- 
ture and  functions  of  the  body  in  health  and  disease.  It  began  among 
the  Greeks  soon  after  the  time  of  Hippocrates  and  reached  its  highest 
development  during  the  nineteenth  century.  It  seeks  to  determine 
accurately  just  what  structural  or  functional  disturbances  underlie  the 
symptoms  of  a  given  disease,  to  what  extent  the  disturbances  are  bene- 
ficial and  to  what  extent  detrimental,  and  what  may  be  done  to  allay 
the  detrimental  and  excite  the  beneficial  disturbances.  It  has  given 
rise  to  refined  methods  of  diagnosis  so  that  lesions  of  the  heart,  the 
lungs,  the  kidneys  and  other  vital  organs  may  be  determined  with  con- 
siderable accuracy,  and  steps  taken  so  far  as  possible  to  overcome  these 
defects  by  use  of  drugs,  operations  or  carefully  regulated  habits  of 
living.  It  has  shown  that  not  all  symptoms  of  disease  are  signs  of  an 
injured  mechanism,  but  rather  may  frequently  be  signs  of  a  vigorous 
healthy  fight  against  invasion.  Thus  fevers  are  frequently,  if  not 
always,  accompanied  by  the  production  of  living  cells  or  of  chemical 
substances  which  attack  invading  disease  germs.  The  fight  may  be  lost 
and  the  mechanism  may  be  permanently  damaged,  but  on  the  other 


Medicine  and  sociology  411 

hand  the  fight  may  be  won.  That  a  fight  won  against  a  mild  invader 
may  enable  the  body  to  resist  a  stronger  one  was  shown  in  the  latter 
part  of  the  eighteenth  century  by  Jenner,  who  discovered  that  inocula- 
tion with  cowpox  will  protect  against  smallpox.  This  great  discovery 
of  vaccination  soon  proved  a  blessing  to  mankind,  but  nearly  a  century 
passed  before  scientific  knowledge  and  methods  became  sufficiently 
developed  to  give  us  the  Pasteur  treatment  for  rabies,  the  Behring 
serum  treatment  for  diphtheria,  and  the  opsonic  therapy  of  Wright,  all 
based  upon  the  idea  either  of  stimulating  the  normal  power  of  the  body 
to  resist  disease  or  of  stimulating  an  animal  to  resist  disease  and  then 
utilizing  its  resistance  products  by  injecting  them  into  the  human  body. 
These  biological  methods  of  treating  infectious  or  contagious  diseases 
are  to  be  contrasted  with  the  merely  chemical  methods  of  which  until 
recently  but  two  were  known  to  be  specific :  mercury  in  syphilis,  derived 
from  the  Arabian  use  of  the  drug  in  cutaneous  affections,  and  quinine 
in  malaria,  derived  in  the  eighteenth  century  from  the  use  by  natives  of 
Peru  of  Peruvian  bark  to  cure  fevers.  Eecently  the  genius  of  Ehrlich 
has  enabled  him  to  add  at  least  one  new  specific  drug,  another  cure  for 
syphilis,  and  to  open  a  new  field  for  work. 

In  another  direction  physiological  research  has  shown  that  when  an 
organ  whose  secretions  are  needed  for  normal  activities  is  deficient  its 
place  may  sometimes  be  taken  by  extracts  from  organs  of  the  lower 
mammals.  The  use  of  thyroid  extract  in  cretinism  and  myxoedema  is 
one  of  the  greatest  gifts  of  physiolog}'  to  medicine.  Nothing  is  more 
astonishing  than  the  development  of  a  cretin,  otherwise  destined  to  a 
dwarfish,  toad-like  existence,  into  a  nearly  or  quite  normal  individual 
when  fed  on  the  extract  of  thyroid  glands  of  the  sheep. 

Modern  surgery  is  an  outgrowth  of  physiological  medicine,  although 
many  of  its  triumphs  are  due  to  asepsis,  and  this  in  turn  is  a  product 
of  the  stage  of  medicine  next  to  be  considered,  the  etiologic. 

Etiologic  medicine  seeks  to  determine  the  causes  of  disease  and  to 
deal  directly  with  these.  It  is  a  direct  outgrowth  of  physiologic  medi- 
cine and  has  really  been  the  aim  of  the  foremost  students  of  the  physi- 
ology of  disease.  While  the  causes  of  some  diseases  have  been  fairly 
well  understood  for  many  years,  etiologic  medicine  was  first  really 
placed  on  a  firm  basis  by  the  genius  of  Pasteur  and  Koch  about  fifty 
years  ago.  In  infectious  and  contagious  diseases  the  specific  organisms 
and  their  mode  of  transmission  have  been  discovered  in  a  large  number 


412  MEDICAL   BESEABCH   AND   EDUCATION 

of  cases,  and  in  others  much  has  been  learned  even  where  the  specific 
organism  has  not  yet  been  discovered.  Thus  one  species  of  mosquito 
is  known  to  transmit  malaria,  another  to  transmit  yellow  fever.  The 
malarial  organism  is  known,  that  of  yellow  fever  is  not.  Malaria  can 
be  fairly  successfully  treated  with  quinine.  There  is  no  specific  for 
yellow  fever.  Both  diseases  can  be  abolished  by  getting  rid  of  the 
mosquito.  Typhoid  fever,  for  which  there  is  no  specific,  can  be  gotten 
rid  of  by  guarding  water  and  food  supplies  and  for  a  time,  at  least, 
guarding  the  public  against  typhoid  carriers,  people  who  harbor  the 
germs  without  themselves  being  sick.  Such  carriers,  however,  would 
probably  not  exist  where  the  water  and  food  supplies  have  been  kept 
pure  for  years,  except,  of  course,  as  they  might  come  in  from  outside. 
Tuberculosis  is  a  more  difficult  problem,  but  by  guarding  the  air  and 
food  supply  and  by  teaching  consumptives  how  to  keep  themselves  from 
infecting  others  great  advances  can  be  made  toward  getting  rid  of  this 
disease. 

Tuberculosis  oSers  perhaps  the  best  example  of  advance  from  the 
physiologic  to  the  etiologic  attitude  toward  disease.  The  history  of 
recent  advance  in  the  study  and  treatment  of  tuberculosis  has  been 
well  summarized  by  E.  W.  Phillip.^ 

The  remarkable  advance  in  the  medical  sciences  during  the  last  half 
century  has  been  due  chiefly  to  the  development  of  research  laboratories 
in  universities,  in  special  research  institutions  and  in  the  government 
service.  In  spite  of  relatively  meager  funds  these  institutions  have 
provided  instruments  and  inspiration  for  search  for  the  truth ;  the  work 
has  been  led  by  men  of  genius,  and  has  been  organized  so  as  to  promote 
cooperation  without  destroying  initiative.  For  the  most  part  these 
research  laboratories  have  been  connected  with  laboratories  of  medical 
schools,  although  in  this  country  such  connection  has  been  unfortu- 
nately too  rare.  Where  such  a  connection  exists,  as  at  Chicago  and 
Eush,  the  investigator  is  stimulated  by  the  youth  about  him  while  the 
younger  men  are  inspired  with  ambition  for  that  real  power  which 
comes  from  scientific  knowledge. 

In  the  application  of  medical  science  to  human  needs  America  has 
been  much  more  backward  than  in  the  advance  of  medical  science. 
This  is  due  probably  chiefly  to  the  fact  that  a  very  few  men  can  advance 

' ' '  Progressive  Medicine  and  the  Outlook  on  Tuberculosis, ' '  British  Medical 
Journal,  1909. 


MEDICINE   AND    SOCIOLOGY  413 

medical  science  enormously  if  they  be  of  the  caliber  to  discover  essential 
truths  and  have  the  right  environment.  One  or  two  research  institu- 
tions or  a  government  inclined  to  give  even  meager  support  to  medical 
investigation  makes  possible  the  work  of  a  Walter  Eeed,  who  is  pri- 
marily responsible  for  the  proof  of  the  conveyance  of  yellow  fever  by 
mosquitoes,  or  of  a  Ricketts,  whose  work  on  spotted  fever  and  on  typhus 
fever  will,  in  spite  of  his  untimely  death,  cause  his  name  to  be  lastingly 
remembered.  On  the  other  hand,  in  order  to  have  an  effective  applica- 
tion of  medical  science  to  human  needs  there  must  be  a  sufficient  num- 
ber of  men  well  versed  in  the  science  to  make  it  possible  to  educate  the 
whole  people  to  an  understanding  of  its  practical  value.  This,  owing 
partly  to  the  backwardness  of  so  many  of  our  medical  schools,  we  have 
not  had.  In  the  Wisconsin  legislature,  a  "  progressive  "  legislature 
at  that,  bills  relating  to  instruction  in  hygiene  and  to  medical  inspec- 
tion in  the  public  schools  have  failed  to  pass  because  a  handful  of 
christian  scientists  exerted  more  influence  tlian  a  medical  profession  of 
three  thousand.  On  the  other  hand,  this  same  legislature  has  been 
quite  liberal  in  providing  for  state  and  county  institutions  for  the  care 
of  tuberculous  patients,  but  here  there  has  been  public  education  largely 
led  by  laymen. 

Demonic  medicine  to  a  large  extent  still  holds  sway.  Among  the 
christian  scientists  the  evil  spirit  is  known  as  "  error,"  among  the 
chiropractics  and  similar  cults  as  "  dislocated  vertebrge,"  among  the 
people  at  large  as  something  vaguely  formulated  but  none  the  less 
something  to  be  driven  out  by  various  kinds  of  patent  medicines  for 
which  each  year  many  millions  of  dollars  are  spent.  The  cures  which 
these  various  forms  of  demonic  medicine  sometimes  effect  are  ascribed 
by  the  scientific  to  the  action  of  the  stimulated  imagination  on  the  body. 
This  has  given  rise  to  a  new  "  psychotherapy  "  in  which  the  effect  of 
mind  on  body  can  be  utilized  scientifically.  Psychotherapy,  however, 
is  to  be  looked  upon  as  a  branch  of  physiologic  medicine.  Demonic 
medicine  has  no  longer  a  place  in  a  truly  civilized  community. 

Hygienic  medicine,  on  the  other  hand,  is  a  lasting  gift  from  the 
Greeks  to  civilized  mankind.  Its  basis  is  personal  hygiene,  the  right 
use  of  exercise  and  rest  of  mind  and  body,  diet,  bathing,  fresh  air, 
sunshine,  proper  clothing  and  the  like.  It  is  primarily  the  medicine 
for  the  home  and  must  depend  largely  on  the  intelligence  and  educa- 
tion of  home-making  women.      In  its  more  specialized  aspects  for  the 


414:  MEDICAL   BESEABCH   AND   EDUCATION 

cure  rather  than  the  prevention  of  disease  it  is  highly  developed  in  our 
better  sanitariums  where  regulated  exercise,  selected  diet,  hydrotherapy, 
electrotherapy  and  the  like  are  carefully  designed  to  restore  a  weakened 
individual  to  healthful  strength  of  body,  and  in  hospitals  for  the  insane 
where  the  aim  is  to  restore  the  mind.  During  the  past  fifty  years  in 
the  hands  of  trained  nurses  it  has  transformed  general  hospitals 
throughout  the  world  from  places  of  excessive  mortality  into  the  safest 
places  in  the  world  in  which  to  be  sick.  For  years  to  come  it  appears 
that  trained  nurses  are  likely  to  be  able  best  to  carry  its  lessons  into 
the  schoolroom  and  the  home  as  they  already  have  into  our  hospitals, 
thanks  largely  to  the  genius  of  Florence  Nightingale.  Modern  surgery 
owes  its  triumphs  fully  as  much  to  the  trained  nurses  in  our  hospitals 
as  it  does  to  anesthetics  or  asepsis.  School  nurses  to  look  after  the 
health  of  school  children  under  the  supervision  of  medical  inspectors, 
and  district  nurses  to  carry  the  lessons  of  hygienic  medicine  into  the 
homes  where  at  present  babies  are  so  badly  cared  for  that  a  fifth  of 
them  die  in  the  first  year  and  a  third  die  before  the  age  of  five,  are 
essential  for  the  advance  of  health  under  the  guidance  of  medical  sci- 
ence. To  the  physician  engaged  in  private  practise  the  nurse  trained 
in  hygienic  medicine  is  indispensable. 

The  practitioner,  although  he  must  be  able  to  apply  or  to  direct 
others  to  apply  appropriate  hygienic  measures,  is  himself  primarily 
responsible  for  physiologic  medicine,  for  the  accurate  diagnosis  of  dis- 
ease and  the  medical  and  surgical  treatment  of  the  sick  individual.  He 
must  be  able  to  determine  accurately  the  condition  of  the  more  impor- 
tant internal  organs  and  be  able  to  apply  drugs  or  other  treatment  with 
due  regard  for  these  conditions.  "While  many  rough-and-ready  methods 
of  diagnosis  may  be  used  in  the  home  or  at  the  office,  many  of  the  more 
refined  methods  are  here  excluded  by  lack  of  time  or  equipment.  Thus 
only  too  frequently  a  serious  condition  is  overlooked  at  its  inception 
and  when  discovered  is  so  far  advanced  as  to  make  a  cure  difficult  or 
impossible.  A  large  percentage  of  cases  of  tuberculosis  are  not  recog- 
nized until  well  advanced,  in  spite  of  the  recent  agitation  about  the 
disease.  This  neglect  to  recognize  tuberculosis  early  will  be  a  standing 
disgrace  to  the  profession  so  long  as  it  exists. 

Under  present  conditions  of  private  practise  crude,  rough-and- 
ready  methods  of  diagnosis  are  in  many  cases  the  best  that  can  be  util- 
ized.    A  refined  method  poorly  executed  is  worth  far  less  than  a  rough 


MEDICINE   AND   SOCIOLOGY  415 

method  carefully  and  intelligently  used  by  an  experienced,  keen-sighted, 
thoughtful  man.  But  the  public  has  a  right  to  demand  the  more 
refined  methods.  Within  a  generation  we  have  seen  most  of  major 
surgery  transformed  from  the  home  to  the  hospital.  There  the  sur- 
geons can  depend  not  only  on  the  nursing  staff  to  provide  better 
hygienic  treatment  than  is  possible  in  the  home,  but  he  can  also  in  a 
well-manned  hospital  depend  on  the  internes  to  utilize  many  of  the 
more  refined  and  time-consuming  methods  of  diagnosis.  To  these  fac- 
tors surgery  owes  no  small  part  of  its  success. 

In  internal  medicine  the  hospital  is  likewise  becoming  more  and 
more  utilized.  Sanitariums  with  highly  developed  means  for  applying 
hygienic  treatment  have  long  been  popular  in  the  treatment  of  chronic 
troubles.  Hospitals  have  not  been  sufficiently  used  for  the  diagnosis 
and  treatment  of  disease  in  its  inception  and  less  severe  aspects,  but 
everything  points  to  a  rapid  development  in  this  direction.  What  is 
needed  is  more  cooperation  and  less  competition  among  the  physicians 
in  any  given  community.  With  better  cooperation  hospitals  fitted  for 
diagnosis  and  treatment  could  readily  be  established  in  sufficient  num- 
bers to  give  every  physician  a  real  hospital  connection,  except  possibly 
in  some  very  small  tovra,s.  Each  hospital  should  have  a  laboratory 
managed  by  one  or  more  men  skilled  in  the  laboratory  diagnosis  of 
disease.  There  would  then  be  no  longer  an  excuse  for  mere  rough-and- 
ready  methods  of  diagnosis.  Nor  would  it  be  necessary  for  the  more 
scientifically  inclined  physician  to  maintain  at  great  personal  expense 
a  private  laboratory  of  his  own.  A  greater  amount  of  specialization  on 
the  part  of  the  various  physicians  in  a  community  would  likewise 
greatly  add  to  their  efficiency,  provided  the  specialization  came  on  top 
of,  not  at  the  expense  of,  a  broad  medical  training. 

In  sanitariums  it  is  customary  to  make  a  general  charge  for  room 
and  treatment,  special  fees  being  made  merely  for  surgical  operations. 
The  physician  at  the  sanitarium,  if  not  the  owner  thereof,  is  usually  on 
a  salary.  At  general  hospitals  the  charge  is  usually  for  room  and 
nursing,  and  other  hospital  care,  the  patient,  if  able  to  pay,  paying  the 
physician  or  surgeon  caring  for  him  directly  for  his  treatment.  The 
medical  staff  of  the  hospital  seldom  is  on  a  salary,  although  a  small 
sum,  in  addition  to  room  and  board,  may  be  paid  the  interne.  At  the 
Johns  Hopkins  Hospital,  where  some  of  the  members  of  the  staff  have 
always  had  some  salary  as  compensation  for  their  care  of  the  indigent, 


416  MEDICAL   BESEABCH   AND    EDUCATION 

it  has  recently  been  proposed  to  put  all  of  the  members  of  the  reo-ular 
staff  on  a  salary  basis,  on  the  understanding  that  they  are  not  to  engage 
in  private  practise.  The  private  patients  at  the  hospital  would  pay  the 
hospital  directly,  and  not  the  attending  physician  or  surgeon,  for  their 
medical  care.  How  wide-spread  such  a  movement  will  become  can  not 
at  present  be  predicted.  In  all  probability,  however,  for  many  years  to 
come  the  majority  of  physicians  will  depend  for  their  support  upon 
fees  from  patients  rather  than  upon  a  salary  from  a  hospital  or  other 
organization.      The  freer  use  of  hospitals  by  no  means  precludes  this. 

On  the  other  hand,  it  is  quite  apparent  that  the  custom  of  the 
employment  of  physicians  on  a  salary  to  give  medical  attendance  to 
groups  of  people  is  growing  throughout  the  civilized  world.  In  public 
institutions  for  the  care  of  the  criminal,  the  insane  and  the  defective,  a?} 
well  as  in  the  army  and  navy,  this  custom  has  long  prevailed  and  in  this 
country  has  received  the  general  sanction  of  the  medical  profession. 
The  employment  of  physicians  by  corporations  to  look  after  men  in 
remote  districts  has  also  received  general  sanction.  But  the  profession 
has  not  looked  favorably  on  the  employment  by  corporations  of  physi- 
cians to  look  after  employees  and  their  families  in  settled  communities 
where  there  is  an  abundance  of  private  practitioners.  Nor  has  the 
profession  looked  with  favor  on  the  employment  at  a  salary  by  lodges 
and  other  social  organizations  of  physicians  to  look  after  members  and 
their  families.  "  Contract  practise,"  as  these  forms  of  practise  are 
called,  has  a  bad  name,  in  large  part  deserved,  because  too  often  a 
physician  will  contract  to  treat  for  a  sum  too  small  to  make  good  service 
possible.  When  a  fair  salary  is  paid  for  first-class  work  no  legitimate 
criticism  can  be  made.  Certainly  there  is  nothing  sacred  about  the 
prevalent  system  of  small  fees  for  visits,  fees  which  resemble  in  some 
respects  tips  to  a  servant  for  personal  service,  except  that  the  physi- 
cian's fee  is  less  often  paid  in  cash.  On  the  other  hand,  there  is  noth- 
ing especially  to  be  commended  in  the  custom  of  the  specialist,  Eobin- 
Hood-like,  to  hold  up  the  rich  sick  to  pay  for  the  sick  poor.  The  public 
at  large  should  pay  for  its  necessary  charity. 

A  physician  should  be  paid  for  his  time  and  his  skill  and  be  paid 
enough  to  make  it  possible  for  him  to  give  good  service  and  improve 
himself  in  his  profession.  But  whether  he  is  paid  a  salary  or  a  fair 
amount  for  a  definite  service  makes  little  difference.  The  evil  to  the 
medical  profession  of  the  medical  insurance  laws  of  Germany  comes 


MEDICINE   AND    SOCIOLOGY  417 

not  from  the  fact  that  the  state  hires  physicians  to  treat  the  insured, 
but  from  the  fact  that  the  state  pays  far  too  little  for  this  service. 

Much  complaint  is  made  of  the  large  numbers  who  seek  free  treat- 
ment at  dispensaries  and  hospitals  in  our  larger  cities,  frequently  a 
quarter  or  more  of  the  population.  It  is  doubtful  if  so  large  a  part  of 
the  population  are  either  paupers  or  dead  beats.  Many  can  not  afford 
fancy  fees  and  know  of  no  way  of  getting  the  best  treatment  except  to 
go  to  a  dispensary  or  hospital  where  treatment  is  organized.  Make  it 
possible  for  the  average  man  to  get  the  benefits  of  organized  treatment 
at  a  moderate  charge  and  a  large  part  of  the  so-called  dispensary  and 
hospital  abuse  will  disappear. 

There  will  doubtless  always  be  some  necessity  for  charity  work. 
The  community  should  pay  the  hospital  and  the  physician  for  such  as  is 
really  necessary.  To  what  extent,  beyond  mere  charity  work,  the  public 
should  pay  for  treatment  of  disease  by  physicians  there  is  room  for  an 
honest  difference  of  opinion.  Some  would  have  all  medical  treatment 
furnished  free  by  the  state,  others  would  have  none.  Most  of  the  pro- 
fession, as  pointed  out  above,  approve  of  the  state  employing  physicians 
in  the  army,  the  navy  and  in  charitable  and  penal  institutions.  In 
public  educational  institutions  the  state  is  under  special  obligations  to 
safeguard  the  health  because  of  the  compulsory  features  of  our  educa- 
tional laws.  While  much  can  be  done  along  the  lines  of  sanitation  and 
preventive  medicine  in  the  schools,  much  treatment  must  be  given  indi- 
vidual pupils  if  this  work  is  to  be  effective.  Where  the  law  provides 
for  medical  supervision  of  the  schools  it  usually  provides  that  the  family 
of  the  child  shall  be  notified  of  the  need  of  treatment  and  shall  be 
expected  to  employ  a  physician  for  this  purpose,  except  in  charity  cases 
where  special  provision  is  made.  At  present  this  is  probably  the  most 
practical  system,  although  only  from  twenty  to  eighty  per  cent,  of 
children  needing  treatment  actually  get  it.  It  is  most  efficient  where 
there  are  school  nurses  to  follow  the  children  to  their  homes  and  explain 
matters  to  the  parents. 

The  need  of  proper  medical  treatment  during  school  life  is  illus- 
trated by  the  son  of  a  well-known  physician.  The  boy  was  slow  in  the 
grades,  and  took  five  years  to  get  through  college.  In  some  doubt  the 
father  allowed  him  to  begin  a  course  in  medicine.  Soon  after  he 
entered  the  medical  school  some  one  suggested  he  needed  eye-glasses, 
although  he  never  had  supposed  he  needed  them.      When  these  were 

28 


418  MEDICAL   EESEABCH   AND    EDUCATION 

obtained  a  new  world  was  opened,  continued  study  became  possible  and 
marked  professional  success  followed.  A  pair  of  glasses  in  the  primary- 
school  might  have  saved  the  boy  some  years  in  school  and  much  chagrin. 

In  normal  schools,  colleges  and  universities  an  increasing  amount 
of  attention  is  being  given  to  caring  for  the  health  of  the  students. 
This  care  takes  several  forms.  Instruction  in  personal  and  public 
hygiene  is  now  quite  general  and  is  required  in  a  majority  of  colleges. 
Departments  of  physical  training  designed  to  promote  physical  health 
are  also  quite  general.  Committees  to  look  after  the  sanitation  of  the 
grounds  and  buildings  are  common,  but  have  not  in  most  cases  been 
given  sufficient  authority  to  do  really  efficient  work.  Class-room  ven- 
tilation, for  instance,  is  in  general  wretched.  In  several  of  the  uni- 
versities infirmaries  are  provided  to  take  care  of  sick  students  and  in 
others  medical  advisers  or  school  physicians  are  engaged  to  advise  or 
treat  those  who  are  ill.  Sometimes  a  special  fee  is  charged  each  stu- 
dent to  provide  funds  to  cover  the  cost  of  this  medical  service,  at  other 
times  it  is  paid  for  out  of  general  university  funds  and  in  some  in- 
stances treatment  is  free  for  poor  students  while  the  well-to-do  are 
supposed  to  pay  for  services  received. 

At  Wisconsin  we  have  a  medical  adviser  with  a  staff  of  three  as- 
sistant physicians,  two  nurses,  a  trained  laboratory  assistant  and  an 
office  attendant.  Careful  medical  examinations  are  made  of  all  fresh- 
men and  of  such  upper  classmen  as  require  it.  Eegular  daily  office 
hours  are  held  for  consultation  with  students,  office  treatment  is  given 
and  some  visiting  is  done  at  rooming  houses  of  students  confined  there 
by  illness,  although  in  severe  or  prolonged  illness  the  student  is  expected 
to  get  his  own  physician  when  he  can  afford  to  pay.  More  treatment  is 
given  than  was  originally  contemplated,  but  our  experience  in  Madison 
has  demonstrated  that  mere  advice  counts  for  little  unless  it  comes 
from  one  whose  ability  to  do  commands  respect.  The  hygienic  talks 
given  to  individual  students  by  the  medical  adviser  and  his  assistants 
are  far  more  effective  than  any  public  lectures  on  hygiene  could  be, 
because  the  staff  commands  the  respect  of  the  students  by  its  ability  to 
diagnose  and  treat  disease.  This,  I  believe,  will  be  found  generally  to 
be  the  case  in  all  institutional  medicine. 

In  the  diagnosis  and  treatment  of  disease  etiology  plays  an  impor- 
tant part,  but  the  great  triumph  of  etiologic  medicine  lies  in  the  possi- 
bilities for  preventive  and  social  medicine  which  it  has  opened  up.     In 


MEDICINE   AND    SOCIOLOGY  419 

preventive  medicine  the  state  through  education,  legislation,  inspection 
and  regulation  plays  an  essential  part.  Preventive  medicine  can  only 
be  made  effective  where  the  state  employs  highly  trained  men  to  look 
after  sanitation  and  hygiene.  Nearly  all  diseases  at  bottom  are  social 
and  can  be  properly  repressed  only  by  social  cooperation. 

Indeed  even  the  most  individualistic  diseases,  congenital  defects  of 
various  sorts,  may  be  frequently  traced  either  to  bad  or  vicious  sur- 
roundings of  the  parents  or  to  a  bad  ancestral  line  on  one  or  both  sides. 
Eugenics,  the  new  science  which  seeks  to  determine  the  laws  necessary 
for  propagation  of  an  improving  species,  will  have  to  be  studied  both 
by  the  family  physician  who  is  to  be  a  wise  councilor  and  by  public 
health  officers  who  aim  to  be  good  teachers  and  guides.  Sociological 
medicine  begins  not  only  before  birth,  but  even  before  conception.  The 
life  of  young  women  must  be  made  healthful,  young  men  must  be  made 
to  understand  the  lasting  effects  to  the  third  and  fourth  generation  of 
drink  and  the  social  vices. 

At  birth  again  sociologic  medicine  has  its  important  part  to  play. 
When  the  clean  hospital  with  its  specialists  comes  to  be  substituted  for 
the  dirty  midwife  and  the  so  frequently  bungling  general  practitioner 
years  of  ill  health  and  suffering  will  be  saved  the  larger  share  of  our 
married  women  and  our  blind  asylums  will  become  one  fourth  too 
large.  Havelock  Ellis  estimates  that  in  England  in  1891  midwives 
were  responsible  for  the  deaths  of  three  thousand  women.  They  were 
doubtless  responsible  for  the  lifelong  suffering  of  many  more.  It  is 
estimated  that  about  a  fourth  of  the  blindness  in  our  blind  asylums  is 
due  to  lack  of  proper  care  of  eyes  at  birth. 

During  infancy  the  death-rate  is  frightful.  While  doubtless  the  fit- 
test survive,  they  do  not  survive  in  the  fittest  way.  An  abundance  of 
well-trained  district  nurses  under  careful  medical  supervision  could  do 
untold  good  in  this  field  of  sociologic  medicine. 

A  fifth  of  the  population  are  in  the  public  schools.  Here  sociologic 
medicine  has  already  made  a  good  start.  In  most  of  the  large  cities 
moderately  efficient  medical  supervision  has  already  been  established 
and  in  the  smaller  towns  it  is  beginning.  Massachusetts  has  a  state 
law  making  it  compulsory  in  the  public  schools  to  provide  a  medical 
adviser  and  several  states  have  permissive  laws.  It  is  the  duty  of  the 
medical  inspector  to  see  that  children  suffering  from  contagious  diseases 
are  excluded  from  the  school  during  the  infectious  period,  to  examine 


420  MEDICAL   BESEABCH   AND    EDUCATION 

for  defects  in  the  eyes,  ears,  nose,  teeth  and  throat,  to  advise  treatment 
when  necessary,  and  in  general  to  look  after  school  hygiene  and  sanita- 
tion. As  already  twice  pointed  out,  the  school  medical  inspector  has 
his  efficiency  greatly  increased  when  school  nurses  are  attached  to  his 
staff.  It  has  been  suggested,  quite  wisely,  I  think,  that  there  be  an 
abundance  of  school  nurses  who  can  not  only  follow  the  children  to 
their  homes  and  see  that  they  are  cared  for,  but  also  act  as  district 
nurses  to  give  advice  concerning  care  of  infants  and  general  hygienic 
conditions.  The  greatest  drawback  to  medical  inspection  has  been  lack 
of  sufficient  funds  to  employ  enough  specially  trained  men  and  women 
at  full  time  to  do  the  work  thoroughly.  Open-air  schools  for  weak 
children  and  special  schools  for  defectives  are  a  natural  outgrowth  of 
medical  supervision  of  school  children.  Chicago  is  to  be  congratulated 
on  the  splendid  start  she  has  made  along  these  lines. 

While  we  can  depend  on  proper  medical  inspection  in  the  schools 
and  school  and  district  nursing  for  a  great  improvement  in  personal 
hygiene  and  in  the  popular  intelligence  concerning  medicine  and 
hygiene,  the  care  of  the  public  health  will  depend  in  no  small  degree 
on  efficient  officers  of  public  health.  At  the  present  time  these  are  rare 
in  the  United  States. 

A  vast  amount  of  preventable  disease  exists  for  which  there  is  no 
intelligent  excuse.  There  should  be  practically  no  typhoid  fever,  but 
thousands  die  from  it  yearly.  Smallpox  should  be  rare,  but  in  the 
middle  west  it  is  quite  common.  Most  of  the  contagious  diseases  could 
be  greatly  reduced  by  more  efficient  boards  of  health.  The  milk  supply, 
in  most  cities,  especially  those  of  moderate  size,  is  far  too  little  intelli- 
gently supervised.  Fortunately,  conditions  are  changing  and  within 
the  present  generation  there  should  be  such  a  demand  for  well-trained 
officers  of  public  health  that  it  will  be  difficult  to  keep  up  the  supply. 
Our  medical  schools  will  recognize  that  the  training  of  public  health 
officers  is  a  duty  equally  important  with  that  of  training  practitioners 
of  medicine.  At  Wisconsin,  next  year,  we  are  to  begin  a  course  in 
public  health  and  we  hope  within  a  short  time  to  find  a  real  demand 
for  such  a  course.  The  splendid  public  health  work  done  by  our  gov- 
ernment in  Cuba,  the  Canal  Zone  and  Manila  shows  what  Americans 
should  soon  be  doing  at  home.  We  need  a  national  health  bureau  and 
we  need  in  each  state  and  in  each  district  and  municipality  in  each 
state  thoroughly  competent  health  officers.  You  young  men  about  to 
graduate  must  do  your  best  to  promote  this  movement. 


MEDICINE   AND    SOCIOLOGY  421 

Efficient  sanitation  depends  above  all  else  on  public  education. 
In  tuberculosis  splendid  progress  has  already  been  made  along  these 
lines,  but  much  more  remains  to  be  done  in  the  general  field.  The 
medical  profession  should  do  far  more  than  it  has  done  to  educate  the 
public.  Sanitary  laws  will  be  efficient  in  a  democracy  just  in  propor- 
tion to  the  general  intelligence  about  hygienic  matters,  and  no  more. 

Medical  advance  depends,  on  the  one  hand,  on  scientific  research,  on 
the  other  on  public  education  along  hygienic  lines.  Every  citizen 
should  be  inspired  with  love  of  personal  and  public  hygiene  as  were  the 
Greeks.  Every  physician  should  be  deeply  grounded  in  physiologic 
medicine  and  provided  with  proper  facilities  for  using  it  practically. 
Every  officer  of  public  health  should  know  thoroughly  the  contributions 
of  etiologic  medicine.  All  efforts  should  be  made  to  promote  these 
most  fundamental  needs  of  society.  While  most  of  you  who  are  grad- 
uating to-day  will  become  private  practitioners,  most  of  you  will  be  in 
a  position  directly  or  indirectly  to  promote  scientific  medicine,  public 
education  and  public  sanitation.  You  have  had  as  students  at  Chi- 
cago University  and  at  Rush  splendid  examples  before  you  in  your 
faculty.  With  such  examples  none  of  you  can  fail  to  play  well  your 
part  in  helping  in  the  organization  of  society  along  more  hygienic  lines 
and  in  the  reorganization  of  medical  practise  to  better  fit  the  needs  of 
modern  society. 


THE  EELATION  OF  RESEARCH  TO  TEACHING  IN 
MEDICAL  SCHOOLS  1 

By  W.  Ophuls,  M.D., 

Peofessoe  of  Pathology,  Leland  Stanford  Junior  University, 

San  Francisco 

Much  of  the  future  development  of  medical  education  will  depend 
on  a  proper  solution  of  the  problem  of  the  relation  of  research  to  teach- 
ing. In  the  course  of  the  last  decade  our  medical  schools  have  made 
great  strides  in  advance.  In  many  of  our  best  institutions  the  teaching 
of  the  fundamental,  more  theoretical  branches  is  as  good  as,  if  not  in 
some  respects  better  than,  in  the  old  centers  of  medical  culture  in 
Europe,  and  we  are  just  about  to  apply  to  our  clinics  what  we  have 
learned  in  our  laboratories.  It  is  at  this  point  that  we  should  pause  for 
a  moment  and  consider  seriously  in  which  way  our  desire  to  place  the 
teaching  in  the  clinics  on  the  same  level  with  that  in  the  laboratories 
can  best  be  accomplished. 

There  are  certain  points  about  which  there  should  be  general  agree- 
ment ;  first  of  all  that  nobody  can  be  a  good  teacher  of  medicine,  surgery 
or  its  various  branches,  any  more  than  of  any  other  branch  of  the 
biologic  sciences,  who  is  not  an  investigator  and  endowed  with  that 
natural  power  of  observation  and  that  inborn  curiosity  in  regard  to  the 
phenomena  which  he  does  observe  which  necessarily  leads  to  research. 
This  does  not,  of  course,  mean  inversely  that  every  good  investigator  is 
a  good  teacher.  To  some  extent,  at  least,  the  true  investigator  is  born 
and  he  can  not  be  entirely  the  result  of  training  even  from  the  most 
ambitious  material. 

It  is  only  through  research  that  the  atmosphere  of  scientific  enthu- 
siasm can  be  created  in  which  the  work  of  the  student  prospers.  It  is 
also  through  research  only  that  the  necessary  bridle  is  placed  on  an 
exuberant  scientific  imagination,  and  the  great  temptation  to  too  rapid 
logical  generalization  is  happily  avoided.  Through  it  one  is  led  to  the 
proper  degree  of  conservatism  in  judging  results,  and  as  a  consequence 

^  Published  in  the  Journal  of  the  American  Medical  Association,  February 
24,  1912, 

422 


BESEABCH   AND    TEACHING  423 

of  it  one  develops  that  state  of  simple-mindedness  and  true  humility 
which  we  admire  so  much  in  all  our  truly  great  men. 

It  also  goes  without  saying  that  no  man,  however  great,  can  attempt 
to  do  research  by  proxy,  which,  however,  seems  to  be  a  common  delu- 
sion. The  most  important  part  of  the  work  must  be  done  personally, 
which  means  that  the  teacher  in  medicine  and  surgery  must  devote 
much  time  to  his  academic  duties ;  how  much  exactly,  is,  to  my  mind,  a 
matter  of  less  importance.  Time  and  experience  only  can  tell  whether 
it  is  wise  to  shut  off  such  men  entirely  from  active  practise  on  the  out- 
side ;  but  that  they  must  devote  the  larger  part  of  their  time  to  teaching 
and  research,  if  they  wish  to  be  effective,  nobody  will  deny. 

The  question  then  resolves  itself  into  this :  How  can  we  attract  the 
men  who  have  the  necessary  qualifications  to  take  teaching  positions  in 
medicine  and  surgery  in  our  medical  schools  ? 

There  is  one  answer  which  we  can  dispose  of  fairly  summarily,  and 
this  is  to  better  present  conditions  by  offering  high  salaries  to  the 
clinical  teachers.  The  argiiment  has  been  made  that,  because  a  physi- 
cian or  surgeon  may  earn  much  money  in  private  practise,  therefore 
the  chairs  of  medicine  and  surgery  must  be  very  highly  endowed  to 
attract  the  best  men.  The  fallacy  of  this  argument  is  at  once  apparent, 
if  we  look  at  similar  cases  which  have  long  been  settled.  Is  not  what  has 
been  said  of  medicine  and  surgery  equally  true  of  chemistry  and  engi- 
neering? Industrial  chemists  and  practising  engineers  may  make,  and 
often  do  make,  vast  fortunes,  larger  by  far  than  even  the  best  practi- 
tioners could  hope  to  accumulate,  still  there  is  no  dearth  of  professors 
of  chemistry  or  of  engineering.  The  right  man  will  never  be  prevented 
from  choosing  an  academic  career  by  such  considerations.  He  must  be 
paid  a  good  living  salary  according  to  his  surroundings,  but  nothing 
more  or  less.  The  salaries  paid  for  professorial  positions  in  general  are 
inadequate,  especially  in  the  larger  cities,  but  from  $8,000  to  $10,000 
a  year  would  certainly  be  ample  at  the  present  time. 

What  the  clinical  teacher,  however,  can  require  and  what  he  must 
require  are  facilities  for  work.  He  must  have  the  necessary  material 
to  work  with,  the  necessary  laboratories  to  work  in  and  the  necessary 
assistance  to  make  his  own  work  effective.  If  money  is  to  be  spent,  it 
is  best  invested  in  this  direction  and  it  will  take  much  money  to  provide 
the  professor  in  the  clinical  branches  with  the  necessary  beds  under  his 
absolute  control,  with  the  necessary  laboratories  and  their  expenses  for 


424  MEDICAL   EESEAECH   AND    EDUCATION 

equipment  and  supplies  and  with  the  necessary  assistants.  On  this 
account  the  provision  of  these  necessities  is  the  one  object  on  which 
those  who  are  in  control  of  our  medical  institutions  should  concentrate 
their  efforts.  On  account  of  the  strong  appeal  which  the  development  of 
such  clinics  would  make  not  only  to  those  who  are  primarily  interested 
in  education  or  in  the  development  of  medical  science,  but  even  more 
to  all  who  are  interested  in  charity,  since  a  proper  medical  treatment 
of  the  poor  is  perhaps  the  one  form  of  charity  which  is  free  from  all 
objections,  the  necessary  funds  should  be  obtained  with  comparative 
ease,  if  only  the  crying  need  for  such  institutions  was  well  understood 
by  the  laity. 

On  account  of  the  large  means,  however,  which  are  necessary  and 
on  account  of  the  urgent,  one  may  say  even  vital,  need  of  our  medical 
educational  institutions  for  such  well-equipped  and  properly  run  clinical 
services,  one  is  justified  in  watching  with  some  apprehension  certain 
recent  developments  which  may  seriously  interfere  with  this  object  and 
withal  with  the  healthy  growth  of  medical  thought  and  knowledge  in 
the  United  States.  I  mean  the  overhasty  establishment  of  special  insti- 
tutes for  medical  research  and  of  special  professorships  of  research 
medicine. 

One  may  be  surprised  at  the  thought  that  special  institutes  for 
medical  research  may  carry  with  them  a  danger  to  general  medical 
education.  What  I  wish  to  say  does  not  apply  so  much  to  those  larger 
institutes  which  are  independent  and  endowed  liberally,  like  the 
Eockefeller  Institute  in  this  country,  the  Pasteur  and  Jenner  institutes 
in  Europe.  The  dangers  there  are  more  evidently  dangers  to  the  men 
within  the  institute  than  to  those  outside.  It  is  true  that  the  men  con- 
nected with  them  are  relieved  of  the  drudgery  of  teaching  and  exami- 
nations; they  are  not  interfered  with  in  any  way  with  their  scientific 
aims  and  aspirations,  but  they  must  miss  the  vitalizing  influence  of 
youth,  of  the  constant  stream  through  the  laboratories  of  classes  of  stu- 
dents with  their  still  undeveloped,  potential  energies,  of  students  from 
whom,  after  all,  the  future  investigators  recruit  themselves.  It  is  true 
that  the  younger  assistants  replace  them  to  a  certain  extent,  but  only 
very  imperfectly.  These  men  must  lose  in  course  of  time  somewhat  the 
sense  of  relation  between  their  own  work  and  the  rest  of  medical  knowl- 
edge. They  must  lose  in  breadth  by  not  being  compelled  to  pay  some 
attention  to  any  part  of  the  field  except  the  part  in  which  they  happen 


BESEAECE   AND    TEACHING  425 

to  be  interested.  Marvelous  results  may  follow  such  intensive  cultiva- 
tion, but  there  also  is,  at  least,  the  danger  which  is  common  to  all  types 
of  forced  cultivation. 

There  is  no  doubt  that  under  certain  circumstances  and  for  certain 
men  such  institutes  are  a  necessity ;  the  Pasteur,  the  Jenner,  the  Rocke- 
feller institutes  and  others  have  justified  their  existence  over  and  over 
again,  but,  to  my  mind,  it  is  the  exceptional  work  which  demands  them 
and  it  is  the  exceptional  character  who  thrives  in  such  surroundings. 
At  any  rate,  they  should  not  be  multiplied  unnecessarily  at  the  expense 
of  funds  which  might  be  available  for  more  general  purposes. 

Such  institutes  constitute  a  real  menace  when  they  are  coupled  up 
with  an  educational  institution,  unless  they  assume  an  educational 
function  and  do  their  share  of  teaching  as  well  as  research.  As  a  general 
principle,  the  research  institute  has  as  much  the  duty  to  teach  as  the 
true  teacher  has  the  duty  to  keep  his  information  alive  by  research. 
The  separation  of  research  from  teaching  in  an  educational  institution 
is  fraught  with  real  danger  because  it  takes  away  from  the  teacher  that 
which  is  his  just  due.  How  does  one  imagine  that  it  will  be  possible 
to  fill  the  teaching  position  with  the  very  best  man  if  there  is  side  by 
side  with  him  another  for  the  express  purpose  of  doing  that  part  of  the 
work  which  should  be  nearest  his  own  heart  ?  It  is  true  that  experience 
shows  that  even  under  these  adverse  conditions  the  "teacher"  often 
does  as  well  as  if  not  better  than  his  research  fellow,  but  I  am  sure  the 
average  board  of  trustees  will  hardly  understand  why,  after  having  so 
splendidly  equipped  the  research  department  or  after  having  it  equipped 
for  them  by  an  endowment,  they  should  do  much  more  for  the  teacher 
than  to  give  just  what  is  absolutely  necessary  for  teaching  purposes. 
If  the  best  man  must  choose  under  such  circumstances  he  is  sure  to 
select  the  research  work,  and  so  the  student,  who  should  certainly  be 
entitled  to  instruction  by  the  best  man  available,  loses. 

The  trouble,  of  course,  in  some  cases,  is  that  research  in  the  abstract 
appeals  more  strongly  to  those  who  are  willing  to  give  the  means  for 
such  purposes;  still  I  believe  that  with  proper  information  such  indi- 
viduals would  be  perfectly  willing  to  give  the  money  in  such  a  way  that 
it  could  be  used  for  research  without  crippling  teaching. 

If  we  apply  this  to  the  conditions  in  medicine  and  surgery  it  is  evi- 
dent that,  far  from  putting  such  a  discouragement  in  the  way  of  our 
future  professors  of  medicine  and  surgery,  we  should  carefully  see  to  it 


426  MEDICAL   BE  SEARCH   AND   EDUCATION 

that  whatever  means  are  available  for  researh  are  at  their  direct  dis- 
posal. It  is  possible  by  good  assistance  to  relieve  a  man  in  many  ways 
from  unnecessary  drudgery  and  in  this  way  give  him  ample  time  for 
that  most  important  part  in  the  pursuit  of  new  knowledge  in  his 
department,  which  he  must  do  himself.  In  fact,  when  we  look  at  the 
life-history  of  our  great  men,  we  find  that  they  have  found  time  for 
such  work  in  spite  of  almost  insurmountable  difficulties,  in  the  way  of 
time  and  equipment,  and  who  will  say  that  the  tremendous  struggle  was 
not  part  of  their  success?  Still  I  firmly  believe  that  unnecessary  fric- 
tion should  be  avoided,  all  clerical  and  administrative  work,  if  neces- 
sary, examinations,  etc.,  got  out  of  the  road ;  then  it  will  become  appar- 
ent that  it  is  not  so  much  teaching  as  a  mass  of  other  much  less  impor- 
tant detail  which  has  clogged  the  machinery. 

In  other  words,  for  our  teaching  positions  in  medicine  and  surgery 
we  must  get  the  best  men  available,  and  in  order  to  get  them  we  must 
carefully  guard  the  positions  which  are  to  be  filled  by  them,  and  see  to 
it  that  they  really  become  attractive  to  the  best  talent. 

From  this  point  of  view  the  establishment  of  chairs  of  research 
medicine  is  an  even  more  serious  mistake.  Research  medicine  is  no 
special  branch  of  medical  knowledge  that  is  worthy  of  a  representation 
in  a  medical  faculty.  The  mere  existence  of  such  a  chair  in  a  way 
reflects  on  the  work  of  the  rest  of  the  members  of  the  faculty.  But  one 
may  say :  Your  objections  are  directed  against  words  rather  than  against 
facts.  The  title  is  merely  a  misnomer  and  experimental  pathology  or 
pathological  physiology  is  really  what  is  meant.  Even  then  the  experi- 
ment remains  objectionable  because  it  places  something  between  pathol- 
ogy and  medicine  which  should  not  be  there.  There  is  no  doubt  that 
our  medical  schools  will  prosper  just  so  much  as  they  will  do  work  in 
"research  medicine,"  but  that  this  type  of  work  should  be  intimately 
connected  with  the  clinics  no  one  will  doubt.  Investigations  of  this 
character  are  the  one  thing  necessary  to  rejuvenate  our  teaching  in 
medicine  and  surgery.  "^AHiy  increase  the  existing  evils  by  giving  the 
men  in  the  so-called  practical  chairs  an  excuse  for  not  doing  what  it  is 
plainly  their  duty  to  undertake?  The  only  reasonable  step  to  take  is 
to  force  our  laboratories  into  our  old  musty  clinics.  We  must  get  fresh 
air,  a  different  atmosphere  and  a  truly  scientific  spirit  into  them,  and 
the  only  way  to  do  this  is  by  making  residence  in  them  congenial  to  the 
true  investigator. 


BESEAUCH   AND    TEACHING  427 

I  do  not  wish  to  be  understood  as  saying  that  the  only  qualification 
which  the  clinical  professor  of  the  future  needs  is  proficiency  in  labora- 
tory work;  far  from  it.  There  are  only  few  laboratory  workers  who 
possess  that  additional  experience  and  those  additional  gifts  of  talent 
and  character  which  can  rightly  be  demanded  of  a  leading  clinician,  but 
that  he  should  have  a  fundamental  training  in  the  methods  of  investi- 
gation in  physiology  and  pathology  seems  self-evident.  The  life-history 
of  all  our  great  clinicians  is  sufficient  warrant  for  this  assertion ;  and  I 
also  believe  that  another  assertion  can  not  be  easily  challenged,  namely, 
that  the  experimental  investigation  of  those  physiologic  problems  which 
are  intimately  connected  with  the  manifestations  of  disease  can  be 
best  done  in  laboratories  directly  connected  with  the  clinics  and  not  on 
the  outside  in  separate  institutions. 

I  present  these  views  for  the  consideration  of  the  members  of  the 
medical  profession  at  large  with  the  hope  that  they  will  take  a  real 
interest  in  the  matter,  first,  because  in  the  long  run  we  shall  get  those 
conditions  in  our  medical  schools  which  the  consensus  of  the  great 
body  of  well-trained  physicians  demands;  and  second,  because  the 
endowments  which  are  to  realize  our  ideals  must  come  largely  through 
the  personal  influence  of  those  who  in  active  practise  come  in  contact 
with  wealthy  individuals  who  are  anxious  to  use  what  they  possess  for 
the  immediate  benefit  of  their  fellow  men  and  for  the  common  welfare 
of  humanity. 


THE  SCIENCE  OF  CLINICAL  MEDICINE :  WHAT  IT  OUGHT 
TO  BE  AND  THE  MEN  TO  UPHOLD  IT^ 

By  S.  J.  Meltzer,  M.D.,  LL.D., 

The  Rockefeller  Institute  op  Medical  Eesearch 

The  honor  of  the  presidency  of  a  society  goes  with  the  privilege  of 
discussing  some  of  the  aims  of  that  society.  Such  a  privilege  becomes 
a  duty  on  the  occasion  of  its  first  birthday.  We  have  to  show  the 
specificity  of  our  objects  to  justify  the  addition  of  a  new  medical  society 
to  the  many  already  in  existence.  As  your  first  president  and  as  one 
of  the  instigators  of  the  movement  which  led  to  the  formation  of  this 
association  permit  me  to  discuss  some  of  the  problems  to  the  solution 
of  which  this  association  wishes  and  hopes  to  contribute. 

Clinical  Medicin-e  as  a  Science 

In  the  first  place,  I  wish  to  discuss  the  problem  of  clinical  medicine 
as  a  science.  In  years  gone  by,  medicine  was  a  unit  and  its  leaders  tried 
to  master  all  its  aspects.  With  the  development  of  scientific  methods 
and  the  growth  of  knowledge  a  process  of  differentiation  took  place. 
Heavy  branches  grew  out  of  the  stem  of  medicine,  broke  off  and  ob- 
tained an  independent  existence.  Anatomy  with  all  its  dependencies 
broke  away  early,  then  followed  physiology,  pathologic  anatomy, 
pharmacology  and  physiologic  chemistry.  Bacteriology  tore  off  the 
branches  of  etiology  and  established  itself  as  an  independent  growth. 
All  these  offsprings  of  medicine  are  now  well  established  as  pure  sci- 
ences; they  still  closely  affiliate  with  the  mother-stem  and  are  often 
designated  as  the  sciences  of  medicine.  That  what  is  left  of  the  old 
stem  is  clinical  medicine.  What  is  the  character  of  this  residuum? 
It  is  generally  designated  as  the  practice  of  medicine.  I  am  not  aware 
that  any  one  has  had  the  courage  to  call  it  a  pure  science.  Those  who 
do  not  like  to  call  it  an  art  say  that  it  is  an  applied  science.  Accord- 
ing to  this  view,  the  relation  of  clinical  medicine  to  the  sciences  of 

^Presidential  address  at  the  first  meeting  of  the  Association  for  the  Ad- 
vancement of  Clinical  Research,  May  10,  1909,  Washington,  D.  C.  Published  in 
The  Journal  of  the  American  Medical  Association,  August  14,  1909. 

428 


THE  SCIENCE   OF   CLINICAL   MEDICINE  429 

medicine  is  that  of  technology  to  science  in  general.  I  am  afraid  that 
this  conception  of  clinical  medicine  is  wide-spread  among  those  who  are 
in  the  practise  as  well  as  among  those  who  are  in  the  sciences  of 
medicine. 

However  this  may  be,  I  feel  sure  that  such  a  view  is  logically 
erroneous  and  practically  harmful.  I  wish  to  plead  for  an  extension  of 
the  process  of  differentiation  also  to  clinical  medicine.  I  am  of  the 
opinion  that  clinical  medicine  as  it  exists  now  is  made  up  of  two  con- 
stituents :  one  part  has  all  the  elements  of  a  pure  science  and  ought  to  be 
coordinate  to  the  other  pure  sciences  of  medicine,  and  the  other  part  is 
the  real  practise  of  medicine,  an  applied  science  which  has  many  ele- 
ments of  an  art.  At  present  both  parts  are  so  closely  interwoven  that 
they  present  the  appearance  of  a  natural  unit  the  splitting  of  which  into 
two  parts  might  appear  to  some  as  an  impossible  and  undesirable 
process.  I  shall  call  to  mind,  however,  that  medicine  made  the  same 
impression  of  an  indivisible  unit  in  the  days  when  pathologic  anatomy, 
physiology,  etc.,  were  inseparable  constituents.  To-day  nobody  doubts 
the  necessity  of  an  independent  existence  for  the  last-named  constituents 
of  former  medicine.  A  considerable  degree  of  separation  of  the  science 
of  clinical  medicine  from  its  practice  is  more  desirable  than  even  the 
separation  of  the  coordinate  sciences,  because  the  requirements  of  sci- 
ences and  practice  are  in  a  certain  sense  mutually  antagonistic  to  one 
another  and  the  simultaneous  cultivation  of  both  branches  with  equal 
attention  is  detrimental  to  the  progress  of  either  of  them. 

There  is  a  fundamental  difference  between  science  and  its  correlated 
practise  in  any  sphere  of  human  activity.  Science  wishes  to  attain 
truthful  knowledge  of  the  subject  it  investigates.  It  attains  this  end  in 
the  safest  way  when  it  is  least  side-tracked  by  any  extraneous  motives. 
The  motive  of  utility  obscures  its  vision,  and  haste  retards  its  progress. 
Practise,  on  the  other  hand,  avails  itself  of  acquired  knowledge  for  the 
purpose  of  attaining  a  certain  useful  end.  The  more  reliable  that 
knowledge  is  which  it  has  to  employ,  the  more  safely  will  it  attain  that 
end.  But  the  use  of  any  part  of  that  knowledge  which  is  indifferent  to 
the  attainment  of  the  useful  end  hampers  the  practical  progress.  In 
other  words,  practise  gains  its  ends  best  the  purer  the  quality  and  the 
smaller  the  quantity  of  the  science  which  it  has  to  use.  Permit  me  to 
say  that  my  advocacy  of  the  separation  of  a  clinical  science  from  its 
practise  is  not  actuated  by  any  disregard  for  the  practise  of  medicine. 


430  MEDICAL   BESEABCH   AND   EDUCATION 

On  the  contrary,  I  entertain  now  and  have  always  entertained  a  stron^ 
conviction  that  the  efficiency  of  practise  should  be  the  supreme  object 
in  medicine.  At  the  same  time  I  feel  sure  that  the  efficiency  of  that 
practise  will  be  best  attained  when  the  search  for  the  knowledge  which 
the  practise  has  to  use  should  be  carried  on  in  the  same  manner  and 
by  the  same  methods  as  are  employed  in  the  search  for  knowledge  in 
other  branches  of  intellectual  activity.  In  other  words,  clinical  research 
should  be  raised  to  a  department  of  a  clinical  science  and  be  theoretically 
and  practically  separated  to  a  considerable  degree  from  the  mere  prac- 
tical interests,  that  is,  separated  so  far  as  the  various  and  variable 
conditions  permit.  It  will  be  the  practise  not  less  than  the  science  of 
medicine  which  will  benefit  by  such  a  separation. 

Now  let  us  see  what  the  domain  of  clinical  medicine  is  and  whether 
it  contains  problems  which  can  be  treated  by  the  methods  employed  in 
pure  science.  The  sciences  of  normal  anatomy  and  physiology  teach 
us  the  structures  and  functions  of  the  normal  body ;  pathologic  anatomy 
tells  us  of  the  anatomic  changes  found  in  a  body  dead  from  one  disease 
or  another.  To  clinical  medicine  is  left  the  study  of  the  phenomena  and 
their  sequence  as  they  occur  in  a  living  body  during  the  entire  course 
of  a  disease.  It  has  to  interpret  these  phenomena  by  known  physiologic 
laws,  to  identify  them  with  similar  phenomena -experimentally  produced 
in  animals  and  it  has  to  correlate  the  phenomena  observed  in  the  course 
of  a  certain  disease  during  life  with  the  anatomic  changes  found  at  the 
post-mortem  examinations  in  case  the  disease  has  a  fatal  termination.  It 
is  also  one  of  the  tasks  of  clinical  medicine  to  study  the  influence  on 
the  onset  and  course  of  phenomena  of  diseases  which  certain  means 
and  remedies  may  exert  whose  physiologic  actions  are  well  established. 
In  other  words,  the  domain  of  clinical  research  comprises  the  study  of 
the  natural  history  of  diseases,  their  physiology  and  their  pharmacology. 
Can  there  be  any  doubt  that  these  studies  constitute  legitimate  objects 
of  a  pure  science  ?  Objections  may  be  raised,  and  will  be  raised  in  cer- 
tain quarters,  against  the  admission  of  the  clinical  science  to  the  sacred 
inner  circle  of  pure  sciences  on  account  of  the  impossibility  in  clinical 
medicine  to  verify  the  conclusions  by  the  experimental  methods.  As- 
suming that  this  is  an  unassailable  fact,  what  of  it  ?  Are  the  problems 
of  biology,  a  science  which  enjoys  an  unassailable  position  in  the 
councils  of  pure  sciences,  all  or  many  of  them  provable  by  experiment  ? 
Or  are  the  sciences  of  paleontology  or  geology  amenable  to  an  experi- 


TBE  SCIENCE   OF   CLINICAL   MEDICINE  431 

mental  proof?  Yet  nobody  questions  the  scientific  right  of  these 
branches  of  human  knowledge.  Furthermore,  admitting  that  clinical 
research  must  necessarily  remain  less  precise  and  its  results  less  convinc- 
ing than  that,  for  instance,  of  physiology.  But,  then,  physiology  itself 
is  again  a  great  deal  less  precise  than  physics  and  chemistry  and  is 
certainly  less  irrefutable  than  anatomy.  Does  this  throw  a  doubt  on  the 
claim  of  physiology  to  be  a  pure  science  ? 

As  to  the  impossibility  of  verifying  certain  conclusions  regarding 
human  diseases  by  human  experimentation,  there  is  still  this  much  to 
say.  Each  disease  is  an  experiment  which  Nature  makes  on  the  organ- 
ism. The  very  large  number  and  the  great  variations  of  these  experi- 
ments of  Nature  offer  favorable  opportunities  for  testing  the  theories 
made  regarding  the  nature  of  these  spontaneous  experiments.  Further- 
more, clinical  research  should,  indeed,  be  coupled  with  animal  experi- 
mentation; any  new  point  of  view  gained  by  observation  in  clinical 
medicine  which  can  not  be  verified  on  human  beings  should  be  tested  by 
experiments  on  animals.  By  such  a  procedure  not  only  clinical  medi- 
cine, but  also  physiology,  may  learn  a  good  deal,  for  which  the  follow- 
ing facts  from  the  recent  history  of  medicine  are  classical  illustrations. 
The  recognition  of  myxedema  as  a  special  type  of  disease  led  to  the 
understanding  of  the  function  of  the  thyroid  glands,  and  the  observa- 
tion of  the  coincidence  of  pathologic  processes  of  the  pancreas  with 
diabetes  led  to  the  discovery  by  clinical  investigators  of  the  glycolytic 
function  of  the  pancreas.  Finally,  it  should  be  borne  in  mind  that  there 
are  lines  of  experimentation  which  may  be  carried  out  even  on  the  sick 
human  being  without  any  detriment  to  him  and  which  can  be  con- 
ducted with  profit  only  by  trained  scientific  observers ;  for  instance,  some 
studies  in  pharmacology  or  in  metabolism.  Among  the  tasks  of  clinical 
medicine  there  is  one  which  is  on  the  borderland  between  the  science  and 
practise  of  medicine,  being  perhaps  of  greater  importance  to  the  latter 
than  to  the  former.  It  is  the  search  for  simple  or  complicated  means 
by  which  established  units  of  diseases  may  be  recognized  safely  and 
perhaps  also  easily.  In  one  word,  it  is  diagnosis.  Since  this  activity  is 
not  carried  on  with  a  purpose  of  adding  knowledge,  it  would  appear  that 
it  belongs  rather  to  the  department  of  the  practise  of  medicine.  Such 
facts  can  be  established  only  by  means  of  careful  critical  observations 
and  it  will  be  more  to  the  purpose  when  at  least  the  development  of 
the  principles  of  diagnosis  should  remain  in  the  hands  trained  in  careful 
methods  of  research. 


432  MEDICAL   BESEABCH   AND    EDUCATION 

After  showing  that  there  is  a  definite  field  for  a  science  of  clinical 
medicine,  the  next  question  is  who  should  be  the  men  to  carry  on  the 
research  in  this  field,  what  should  be  their  qualifications  ?  In  the  first 
place,  they  must  have  a  training  fitting  them  to  carry  out  investiga- 
tions in  conformity  with  the  requirements  existing  in  all  pure  sciences. 
They  must  not  only  be  informed  and  trained  in  the  other  sciences  of 
medicine,  but  must  have  carried  on  various  investigations  in  one  or 
more  of  these  pure  sciences,  so  as  to  become  familiar  with  careful  scien- 
tific methods  and  imbued  with  a  scientific  spirit.  They  will  thus  learn 
best  how  to  shape  a  problem  so  as  to  make  it  amenable  to  a  solution; 
how  to  marshall  the  consecutive  steps  of  an  investigation  so  as  to  bring 
out  the  reply  to  the  question  in  hand.  They  will  learn  to  avoid  bias 
in  the  search,  to  apply  criticism  to  the  findings;  they  will  learn  not  to 
trust  only  few  facts,  not  to  rejoice  prematurely  over  findings  and  not 
to  be  disheartened  by  failures.  They  will  thus  acquire  the  habits  and 
the  tastes  of  the  investigator,  the  scientist,  which  may  then  stick  to  them 
for  life. 

However,  after  all  these  preparations  they  must  select  clinical  re- 
search as  the  main  field  of  their  scientific  activity.  Clinical  science  will 
not  thrive  through  chance  investigations  by  friendly  neighbors  from  the 
adjoining  practical  and  scientific  domains.  "  Such  volunteer  service 
which  for  the  present  is  keeping  up  the  cultivation  of  the  unacclaimed 
region  is  most  certainly  very  welcome.  But  the  acclamation,  cultiva- 
tion and  maintenance  of  a  field  of  pure  science  of  clinical  medicine  can 
not  be  accomplished  by  chance  services  from  volunteers;  for  such  a 
purpose  we  need  the  service  of  a  standing  army  of  regulars.  The  in- 
vestigator in  clinical  science  must  devote  the  best  part  of  his  time  and 
intellectual  energies  to  the  cultivation  and  elevation  of  this  field  just  as 
the  physiologist  does  in  his  domain — or  at  least  as  he  ought  to  do.  For 
the  sake  of  elucidation  let  us  compare  the  relations  of  a  science  of 
clinical  medicine  to  its  practise  with  the  relations  of  science  to  tech- 
nology in  any  part  of  physics  or  chemistry.  Let  us  take  electricity  as 
an  instance.  In  the  electrical  industry  there  is  a  large  corps  of  electrical 
engineers  who  are  bright,  inventive  and  on  the  alert  to  make  practical 
use  of  any  newly  discovered  principle  in  general.  Some  practical  engi- 
neers manage  to  make  valuable  contributions  to  the  theoretical  knowl- 
edge of  their  branch.  Nevertheless  the  science  of  electricity  is  in  the 
hands  of  pure  scientists  who  are  setting  the  pace  of  progress  in  the 


TEE   SCIENCE   OF   CLINICAL   MEDICINE  433 

correlated  practical  branch.  It  is  the  discovery  in  pure  science  which 
makes  great  inventions  possible.  It  was,  for  instance,  the  purely  scien- 
tific demonstration  by  Hertz  of  the  existence  of  electric  waves  that  gave 
the  impetus  to  and  made  the  invention  of  wireless  telegraphy  possible. 
The  following  is  a  quotation  from  the  presidential  address  of  Professor 
Nichols  before  the  Association  for  Advancement  of  Science  -.^ 

Communities  having  the  most  thorough  fundamental  knowledge  of  pure  science 
will  show  the  greatest  output  of  really  practical  inventions. 

This  is  surely  true  also  for  medicine.  And  let  me  say  to  you  that 
the  Hertzes,  the  Roentgens,  the  Bunsens,  the  Emil  Fischers  and  a  host 
of  others,  who  are  the  real  creators  of  knowledge  and  invention,  are 
satisfied  to  live  on  comparatively  small  salaries,  while  it  is  within  their 
easy  reach  to  make  twenty  times  the  amount  of  their  salaries  as  con- 
sultants, if  they  would  be  willing  to  give  up  a  part  of  their  time  which 
they  devote  to  investigations  in  pure  science.  Now,  the  leaders  in  prac- 
tical engineering  in  electricity  surely  compare  favorably  with  the  leaders 
in  the  practise  of  medicine  with  regard  to  the  completeness  of  their 
knowledge  in  the  respective  spheres.  "While  thus  the  search  for  Icnowl- 
edge  in  electricity  is  carried  on  by  men  devoting  themselves  to  pure 
science,  the  search  for  knowledge  in  clinical  medicine  is  left  in  the 
hands  of  men  who  devote  most  of  their  time  and  energies  to  their 
practise  and  to  the  golden  fruit  it  bears.  Under  such  circumstances, 
how  shall  we  expect  to  find  the  progress  in  science  and  practise  of  medi- 
cine keeping  abreast  with  the  striking  progress  to  be  met  with  in  other 
branches  of  science  and  practise? 

A  few  years  ago  I  tried  to  fix  the  responsibility  for  the  shortcoming 
of  internal  medicine  to  physiology,  because  this  science  is  keeping  aloof 
from  medicine  and  its  problems.^  Anatomy,  which  gave  its  undivided 
attention  to  the  human  structures,  prepared  an  excellent  basis  for  a 
successful  surgery,  the  problems  of  which  are  essentially  mechanical  in 
character.  The  problems  of  clinical  medicine  are  essentially  of  a  func- 
tional character,  and  the  enlightenment  which  it  requires  must  come 
from  physiology.  This  science,  however,  developed  a  tendency  to  keep 
at  a  distance  from  medicine  on  account  of  the  inexactness  of  the  latter. 
There  is  an  improvement  to  be  noted  in  this  regard;  there  is  a  grow- 
ing tendency  in  physiology  nowadays  to  pay  greater  attention  to 
medical   problems.     However,   even   if   physiology   and   other   related 

^  Science,  Jan.  1,  1909,  p.  5. 

^Congress  of  Science  and  Art,  1904,  V,  395;  chairman's  address. 

29 


434  MEDICAL   BE  SEARCH   AND    EDUCATION 

medical  sciences  would  devote  all  their  time  and  energy  to  the  study  of 
purely  medical  problems,  it  would  not  bring  about  a  radical  solution  of 
our  perplexing  problem.  Neither  will  this  be  accomplished  by  the 
creation  of  chairs  for  experimental  medicine.  The  regeneration  or 
rather  creation  of  a  science  of  clinical  medicine  must  come  from  the 
innermost  of  medicine  itself.  It  is  true,  as  stated  before,  that  the  men 
who  are  to  tackle  these  problems  must  have  a  thorough  training  in  the 
sciences  allied  to  medicine,  but  the  center  of  their  activities  must  be 
within  clinical  medicine  itself.  They  must  have  a  bringing  up  within 
medicine,  their  minds  must  have  been  filled  up  with  thinking,  worrying, 
brooding  over  practical  and  theoretical  problems  of  clinical  medicine. 

Let  me  recapitulate.  There  is  a  necessity  for  a  difEerentiation  of 
clinical  medicine  into  a  science  and  a  practise.  The  clinical  science 
has  well-defined  objects  and  is  a  most  important  department.  It  must 
be  managed  by  a  set  of  men  specially  trained  for  and  almost  exclusively 
devoted  to  that  task.  Without  the  development  of  such  a  department 
of  clinical  science  the  efficiency  of  the  practise  of  internal  medicine  will 
lag  behind,  no  matter  how  progressive  the  allied  sciences  of  medicine 
are  and  how  great  their  efforts  to  be  useful  to  medicine  may  be. 

The  Conditions  as  Thet  Actually  Exist 

In  conjunction  with  the  foregoing  considerations  let  me  glance  at  the 
conditions  of  clinical  medicine  as  they  actually  exist  here  and  abroad.  I 
may  state  that  neither  abroad  nor  here  do  we  find  a  separate  class  of 
investigators  confining  their  activity  solely  to  the  domain  of  the  science 
of  clinical  medicine.  Everywhere  science  and  practise  of  clinical  medi- 
cine go  hand  in  hand.  We  may,  however,  admit  at  the  outset  that  there 
is  an  enormous  difference  in  the  status  of  medical  research  between 
abroad  and  here.  Let  us  take  the  development  and  the  present  status 
of  clinical  medicine  of  the  German-speaking  countries  as  an  illustra- 
tion of  the  conditions  abroad.  We  shall  notice  that  there  the  mother 
stem  of  medicine  managed  to  retain  a  scientific  aspect  despite  all 
processes  of  differentiation. 

When  for  the  first  time  pathologic  anatomy  broke  away  completely 
from  medicine  and  was  taught  by  Eokitansky  at  the  University  of 
Vienna  as  an  independent  branch  of  medical  science,  we  find  that  at  the 
same  time  and  at  the  same  place  the  celebrated  Skoda  was  teaching  the 
remaining  trunk  of  clinical  medicine  as  a  natural  science,  constructing 


THE   SCIENCE   OF   CLINICAL   MEDICINE  435 

the  methods  of  auscultation  and  percussion  on  a  sound  basis  and  estab- 
lishing a  firm  connection  between  the  intravitam  diagnosis  and  the  post- 
mortem findings.  The  purely  anatomic  tendencies  of  that  celebrated 
school  of  medicine  which  unfortunately  gave  birth  to  nihilism  in  medi- 
cine, were  soon  curbed  by  the  appearance  of  Virchow  on  the  medical 
scene  in  Berlin.  While  also  working  for  the  establishment  of  the 
pathologic  anatomy,  gross  and  histologic,  as  an  independent  natural 
science,  he  manifested  throughout  his  long  life  a  deep  interest  in  the 
development  of  clinical  medicine  on  sound  lines.  At  the  very  beginning 
of  his  brilliant  career  we  find  him  stating  (in  the  prospectus  to  the  first 
volume  of  his  Archiv)  that  practise  of  medicine  should  be  an  applied 
science  and  the  ideal  of  the  science  should  be  a  complete  pathologic 
physiology.  The  great  clinical  contemporaries  of  Virchow  strove  for  a 
similar  ideal.  Frerichs  introduced  chemistry  and  Ludwig  Traube  the 
methods  of  experimental  physiology  into  the  domain  of  clinical  medicine. 
I  shall  not  dwell  here  further  on  historical  details.  I  shall  only  say 
that  clinical  medicine  in  Germany  remained  true  to  this  ideal  through- 
out all  these  years  of  marvelous  growth  of  medicine.  The  exponents  of 
clinical  medicine  in  Germany  are  the  flag  bearers  of  pathologic  physiol- 
ogy. The  contemporary  clinicians  master  the  immense  knowledge  and 
manual  skill  which  contemporary  clinical  medicine  demands  of  its 
disciples,  and  nearly  all  of  them  are  themselves  diligently  adding  new 
facts  to  the  store  of  medical  science.  I  do  not  need  to  tell  you  the  par- 
ticulars. Some  of  you  know  from  personal  experience  such  master 
clinicians  as  Miiller,  Krehl,  Kraus,  Minkowsky,  and  a  good  many 
others  like  them.  However,  the  standard  of  medicine  is  kept  high  not 
only  by  the  heads  of  university  clinics;  the  various  members  of  their 
staffs,  heads  of  hospitals  and  their  staffs  and  a  host  of  volunteer  workers 
are  continually  digging  for  new  fruit  in  the  soil  of  clinical  medicine. 
The  medical  literature  is  full  of  original,  first-rate  work  in  the  science 
of  clinical  as  well  as  of  experimental  medicine  contributed  by  men 
whose  main  abode  is  clinical  medicine. 

Now  there  is  in  Germany  no  special  chair  for  the  science  of  clinical 
or  even  experimental  medicine.  All  these  contributors  to  medical  sci- 
ence are  in  a  sense  simply  medical  practitioners.  What  is  the  secret  of 
their  scientific  success?  It  is  simply  this:  to  these  men  science  is  the 
first  and  practise  the  second  object  of  their  life.  To  most  of  the  leaders 
of  medicine  in  Germany  the  tasks  of  gaining  and  diffusing  knowledge 


436  MEDICAL   BE  SEARCH   AND    EDUCATION 

receive  their  first  attention  and  the  consultation  practise  comes  in  last. 
Again,  these  very  leaders  before  they  have  acquired  their  commanding 
positions  spent  many  years  of  their  life  in  preparing  themselves  for  it ; 
in  training  in  scientific  methods,  in  acquiring  knowledge  in  the  allied 
sciences  and  in  the  science  and  practise  of  clinical  medicine,  living 
meanwhile  on  small  incomes,  having  no  private  practise  at  all  or  having 
a  practise  too  small  to  interfere  with  their  life  ambition.  You  can  not 
lead  such  a  life  unless  you  are  possessed  by  idealism  and  a  scientific 
spirit.  That  is  the  key  to  their  success.  And  when  these  men  become 
teachers,  they  can  not  fail  to  impart  this  ideal  spirit  to  their  students. 
That  is  the  way  they  themselves  received  it.  But  they  received  it  also 
in  the  institutions  of  their  early  education,  where  sport  and  habits  of 
millionaires'  sons  are  not  the  factors  which  form  the  character  of  the 
youth.  They  received  it  from  the  people  among  whom  they  grew  up, 
among  whom  the  worth  of  the  individual  is  not  measured  exclusively  by 
a  gold  standard.  They  received  it  from  the  care  and  encouragement 
of  the  government  which,  no  matter  what  its  political  ideals  may  be, 
never  loses  sight  of  the  fact  that  the  cultivation  of  science  is  one  of  the 
greatest  assets  of  a  people.  They  received  it  in  the  traditions  of  medi- 
cine of  their  country;  even  before  the  new  era  when  medicine  was  all 
in  a  cloud  of  so-called  natural  philosophy,  only  the  substance  of  medi- 
cine was  all  wrong,  its  spirit  was  all  right. 

That  is  the  situation  abroad.  Now  let  us  look  at  the  development  and 
the  present  status  of  clinical  medicine  in  this  country.  At  a  glance  one 
observes  with  amazement  that  nearly  all  the  factors  which  favored  the 
development  of  a  scientific  spirit  in  Germany  are  absent.  However,  I 
shall  not  try  to  enumerate  all  the  shortcomings  with  which  the  develop- 
ment of  medicine  in  this  country  had  and  still  has  to  contend.  There 
is  no  educational  advantage  in  doing  it  and  you  are  all  familiar  with 
the  situation.  On  the  contrary,  I  take  pleasure  in  pointing  out  the 
encouraging  fact  that,  despite  all  the  difficulties,  medicine  in  this 
country  gradually  rose  to  a  commanding  position  in  many  respects.  It 
is  an  instructive  and  stimulating  fact  that  the  progress  of  medicine  in 
this  country  was  carried  on  through  the  efforts  of  a  few  high-minded 
men  or  groups  of  men  who  at  various  times  transplanted  the  spirit  pre- 
vailing abroad  into  this  country.  I  shall,  of  course,  not  attempt  to 
enter  into  the  particulars  of  the  history  of  this  progress.  I  wish  to  refer 
briefly,  however,  to  a  few  phases  "in  this  history.     In  the  first  important 


THE   SCIENCE   OF   CLINICAL   MEDICINE  437 

phase,  clinical  medicine  in  America  received  an  elevating  impulse 
through  the  activities  of  a  group  of  medical  men  who  continued  their 
studies  in  France,  where  they  came  especially  under  the  influence  of 
the  famous  clinician  Louis.  Statistical  methods  of  observation  of 
diseases  and  diagnosis  by  auscultation  and  percussion  became,  then, 
the  chief  characteristics  of  internal  medicine  in  this  country.  During 
the  second  period,  young  American  physicians  pursued  their  post- 
graduate studies  in  Austria  and  Germany.  They  brought  home  a 
knowledge  of  gross  and  minute  pathologic  anatomy  and  an  aptitude  for 
the  use  of  the  microscope.  Pathologic  societies  were  started  and  the 
teachers  of  medicine  began  to  give  separate  lectures  on  pathologic 
anatomy  and  to  instruct  in  the  use  of  the  microscope  as  a  clinical  aid. 
The  studies  and  teaching  of  these  new  subjects  gave  at  that  time  a 
scientific  flavor  to  clinical  medicine.  The  last  period  covers  about  the 
three  last  decades  with  the  contradictory  results  of  which  we  are  con- 
fronted to-day.  Again,  medical  men  went  abroad  for  postgraduate 
studies  and  perhaps  in  larger  numbers  than  ever.  But  what  this  high 
class  of  young  medical  men  studied  there  now  was  no  longer  in  the 
direct  interest  of  clinical  medicine;  they  trained  themselves  in  the 
intricacies  of  the  sciences  of  medicine.  The  results  of  the  studies  of 
this  period  were  again  of  great  benefit  to  medicine  in  this  country;  in 
fact,  they  were  of  greater  benefit  than  ever.  In  a  comparatively  short 
period  the  special  sciences  of  medicine,  thanks  to  the  activity  of  a 
brilliant  group  of  men,  have  gained  a  strong  foothold  in  this  country; 
special  chairs  and  laboratories  were  created  in  many  schools  of  medi- 
cine for  pathology,  physiology,  bacteriology,  pharmacology  and  ph3'sio- 
logic  chemistry.  The  work  which  is  being  accomplished  now  in  these 
laboratories  compares  favorably  with  the  work  done  in  the  countries 
with  older  scientific  traditions  and  much  more  favorable  surroundings. 
However,  by  this  very  departure  clinical  medicine  itself  suffered  a  visible 
retardation  in  the  development  of  its  own  department.  I  discuss  this 
phase  not  with  pleasure,  but  the  truth  must  be  said.  To  my  mind  it  is 
a  fact  that  the  leading  clinicians  of  this  generation  do  not  compare 
favorably  with  their  predecessors  in  this  country,  not  to  speak  of  a 
comparison  with  the  leaders  of  clinical  medicine  in  other  countries. 
One  of  the  reasons  for  the  retardation  in  the  progress  is  the  loss  to 
clinical  medicine  of  the  brainy  men  who  now  devote  their  energies  to  the 
pure  sciences  of  medicine.     Another  reason  may  be  found  in  the  fact 


438  MEDICAL   BESEABCE   AND    EDUCATION 

that  by  giving  up  pathologic  anatomy  and  microscopy  to  special  depart- 
ments clinical  medicine  lost  that  part  which  has  given  it  formerly  its 
scientific  character.  An  evident  drawback  to  the  progress  of  internal 
medicine  in  this  country  is  the  fact  that  its  teaching  at  the  present  time 
is  mostly  still  in  the  hands  of  men  who  received  their  medical  training 
nearly  exckisively  in  this  country  and  at  a  time  when  pathologic  an- 
atomy was  the  exclusive  basis  and  auscultation  and  percussion  practically 
the  exclusive  methods  of  diagnosis.  But  in  the  last  twenty-five  years 
internal  medicine  changed  its  aspect  greatly.  The  men  who  want  to 
teach  the  medicine  of  to-day  must  have  an  education  and  training 
radically  different  from  those  which  were  customary  and  sufficient  in 
former  years. 

However,  the  greatest  evil  of  them  all  is  the  deplorable  fact  that  in 
most  instances  internal  medicine  is  taught  in  this  country  by  very  busy 
consultants  who  can  give  only  a  small  fraction  of  their  time  and  mental 
energy  to  this  one  of  the  side  issues  of  their  busy  lives.  Teaching  medi- 
cine and  furthering  its  science  is  a  very  serious  business  which  ought 
to  be  carried  on  by  men  who  are  ready  to  devote  all  or  most  of  their 
time  to  it. 

Here  are  problems  for  you  to  solve.  The  progress  of  clinical  medi- 
cine in  this  country  has  to  be  accelerated  again.  We  might  reach  the 
level  which  we  have  seen  to  exist  abroad.  But  we  ought  to  strive  to  get 
still  higher ;  in  this  field  lack  of  modesty  is  a  stimulating  virtue.  Look 
at  the  allied  sciences  of  medicine,  the  level  of  which  they  have  reached 
in  a  comparatively  short  time  without  any  tradition  and  only  through 
the  activity  of  a  small  group  of  high-minded  men.  The  progress  of 
medicine  in  this  country  was  always  carried  on  by  the  few  and  not  by 
the  masses.  Clinical  medicine  must  reclaim  some  of  the  brainy  young 
men  who  were  enticed  by  the  sciences  of  medicine.  You  represent  a 
new  generation.  You  have  had  an  education  and  a  training  in  modern 
medicine  and  the  allied  sciences.  You  have  a  training  in  investiga- 
tion, the  constitution  requires  it  of  you.  The  constitution  which  you 
have  adopted  shows  your  spirit.  Among  its  objects  is  "  the  cultivation 
of  clinical  research  by  the  methods  of  the  natural  sciences  and  the 
diffusion  of  a  scientific  spirit  among  its  members."  But  you  will  ac- 
complish more;  the  constitution  imposes  on  you  the  obligation  to  be 
active  in  the  diffusion  of  the  principles  of  the  society,  particularly  among 
the  students  who  come  under  your  charge.     I  would  recall  this  obliga- 


THE   SCIENCE   OF   CLINICAL   MEDICINE  439 

tion  to  the  minds  of  the  members  who  were  called  within  this  year  to 
chairs  of  medicine  at  influential  places.  The  constitution  does  not 
keep  you  down  exclusively  to  science,  but  let  me  tell  you:  beware  of 
practise.  It  is  a  bewitching  graveyard  in  which  many  a  brain  has  been 
buried  alive  with  no  other  compensation  than  a  gilded  tombstone. 

One  last  word.  The  men  whom  you  now  see  sitting  on  the  bank 
left  behind  while  the  boat  of  progress  swiftly  glides  away  with  fresh 
winds  and  under  fresh  sails  were  themselves  in  their  youth  passengers 
of  similar  boats  and  cut  faces  at  others  who  were  left  behind.  Be  gen- 
erous to  them,  but  do  not  repeat  their  mistakes.  The  secret  is :  never 
leave  the  boat. 


THE  PUBLIC  AND  THE  MEDICAL  PROFESSION^ 

By  James  Ewing,  A.M.,  M.D., 

Professor  of  Pathology,  Cornell  University  Medical  College 

To-night  the  New  York  Academy  of  Medicine  enters  formally  upon 
the  sixty-fourth  year  of  its  activities.  It  was  in  1847  that  one  hundred 
and  thirty-two  New  York  doctors,  led  by  John  Stearns,  A.  H.  Stevens, 
Valentine  Mott  and  Isaac  Wood,  resolved  to  incorporate  the  higher  in- 
terests of  the  medical  profession  in  the  New  York  Academy  of  Medicine. 
The  objects  in  mind  at  that  time  were  mainly  three :  (1)  The  unification 
of  the  regular  practitioners  of  medicine,  (2)  the  elevation  of  the  stand- 
ard of  medical  education,  and  (3)  the  promotion  of  the  interests  of  med- 
ical science. 

The  strong  ideals  of  those  early  days  far  outshone  the  modesty  of 
their  organization,  for,  as  Dr.  William  Detmold  recalled  many  years 
later,  the  early  meetings  of  the  academy  were  held  in  a  dingy  room  over 
a  coal  yard  in  Wooster  street ;  the  social  ambitions  of  the  new  institution 
were  most  meager ;  not  even  a  beginning  of  a  library  was  attempted ;  and 
the  idea  of  a  permanent  building,  which  was  sorely  needed  for  the  vari- 
ous uses  of  the  institution,  seemed  and  proved  to  be  a  far-distant  dream. 

The  foundations  of  a  permanent  building  fund  were  laid  in  1853 
when  the  surplus  contributions  of  the  doctors  for  the  entertainment  of 
the  American  Medical  Association  were  set  apart  for  that  purpose.  Yet 
it  was  only  after  an  interval  of  twenty-two  years  and  through  oft-re- 
peated efforts  that  in  1875  the  academy  was  able  to  purchase  a  home  at 
12  West  Thirty-first  Street.  A  notable  ceremony  marked  the  occupation 
of  this  first  permanent  building  of  the  academy,  and  the  addresses  on 
that  occasion  revealed  what  strenuous  efforts  and  almost  religious  en- 
thusiasm had  been  called  forth  in  the  endeavor  to  provide  a  great  com- 
munity with  a  home  for  its  academy  of  medicine.  The  fervent  pioneer 
spirit  of  the  founders  of  the  academy  is  well  displayed  in  the  words  of 
John  Stearns,  who  in  an  early  address  declared  that  if  he  could  be  as- 
sured of  its  uninterrupted  and  enduring  prosperity  in  disseminating 

^  Anniversary  address  of  the  New  York  Academy  of  Medicine,  delivered 
November  16,  1911.     Published  in  the  Medical  Record,  December  16,  1911. 

440 


TBE  PUBLIC   AND    THE   MEDICAL   PHOFESSION  441 

health  and  happiness  and  the  sustaining  principle  of  life  he  would  die  in 
peace  with  effusions  of  gratitude  and  praise  to  Almighty  God  for  his  per- 
manent blessings  upon  their  labors. 

It  does  not  appear  that  the  founders  of  the  academy  received  or 
looked  for  any  material  support  from  the  public.  Both  the  fruitless  and 
the  successful  appeals  that  in  1875  had  accumulated  $14,000  had  been 
made  exclusively  by  the  three  hundred  members  of  the  academy  itself. 
Likewise  in  the  further  material  growth  which  led  to  the  purchase  of  the 
present  site  and  has  brought  us  to-day  to  the  necessity  of  extensive  en- 
largements of  the  academy  building,  the  appeal  has  been,  with  a  few 
noteworthy  exceptions,  to  the  medical  profession  itself.  A  glance  at  our 
sister  communities  shows  that  the  history  of  the  New  York  Academy  of 
Medicine  is  being  or  has  been  reproduced  in  many  other  American  cities. 
EveryM^here  the  demands  of  the  higher  ideals  of  medicine  lead  to  the 
creation  of  such  institutions,  and  everywhere  the  appeal  is  met  chiefly  or 
wholly  by  the  medical  profession. 

Throughout  the  long  period  of  our  material  growth  the  intellectual 
activities  of  this  academy  have  more  than  maintained  an  equal  pace. 

The  132  original  members  have  been  succeeded  by  the  present  mem- 
bership of  1,280.  While  it  is  becoming  less  and  less  a  mark  of  distinc- 
tion to  be  a  fellow  of  the  academy,  it  is  more  and  more  a  notable  delin- 
quency for  an  eligible  physician  not  to  become  a  member.  The  single 
section  of  the  early  days  has  expanded  into  a  score  of  special  bodies,  each 
pursuing  effectively  its  special  field  in  regiilar  conferences.  The  general 
meetings  of  the  academy  draw  the  most  distinguished  representatives  in 
America  of  every  branch  of  medical  art.  The  interests  of  every  branch 
of  medical  science  are  warmly  supported  by  the  authorities  of  the  acad- 
emy, and  here  have  centered  the  activities  of  several  independent  med- 
ical organizations,  some  of  which,  as  the  New  York  Pathological  Society 
and  the  County  Medical  Society,  are  more  venerable  than  the  academy 
itself,  and  our  hospitality  is  sought  by  several  bodies  representing  allied 
sciences  and  arts.  Scores  of  distinguished  visitors  from  abroad  remem- 
ber and  many  have  recorded  their  welcome  here.  The  records  of  the 
academy  show  that  from  the  earliest  days  the  best  work  and  the  best 
thought  of  the  leaders  in  New  York  medicine  have  been  presented  at  its 
meetings,  and  those  who  are  familiar  with  the  submerged  history  of  the 
academy  know  that  its  life  has  always  depended  upon  the  unfaltering  de- 
votion of  a  long  list  of  famous  physicians  who  have  planned  and  worked 
for  its  interests. 


442  MEDICAL   BESEABCH   AND   EDUCATION 

Yet  the  scope  of  the  academy  is  not  confined  to  the  current  activities 
of  its  various  sections  and  allied  societies.  The  library  of  the  academy 
has  been  the  special  pride  of  many  of  the  foresighted  guardians  of  the 
past,  and  is  to-day  the  second  most  complete  collection  of  medical  litera- 
ture in  America.  It  is  freely  accessible  not  only  to  the  entire  medical 
profession,  but  to  the  general  public  as  well,  and  it  is  probably  the  most 
actively  used  collection  of  books  in  the  Avorld.  It  would  be  difficult  to 
estimate  the  significance  of  the  influence  thus  exerted,  through  the  dis- 
semination of  knowledge,  not  only  in  all  branches  of  the  medical  profes- 
sion, but  also  in  veterinary  science,  dentistry,  biology  and  chemistry,  and 
in  the  steadily  enlarging  scope  of  the  layman's  acquaintance  with  medi- 
cine. May  we  not  pause  and  compare  with  pride  the  relative  significance 
of  this  priceless  collection  of  books  stored  in  dark  corners  with  that  of 
our  magnificent  and  aristocratic  neighbor  the  New  York  Public  Library  ? 

The  public  services  of  the  academy  extend,  also,  to  the  consideration 
and  support  of  the  interests  of  hygiene  and  sanitation  and  many  peculiar 
problems  of  sociology  and  public  morals,  which  can  be  solved  only 
through  intimate  acquaintance  with  their  medical  aspects. 

Truly  medicine  is  still  the  mother  of  the  sciences,  and  the  Academy 
of  Medicine  in  New  York  has  established  itself  as  the  home  and  guiding] 
hand  of  all  the  influences  which,  according  to  worthy  tradition  and  crit-^ 
ical  experience,  further  the  realization  of  the  ideals  of  the  medical  pro- 
fession.   It  would  be  a  worthy  task,  in  which  one  might  engage  with  en- 
thusiasm, to  fully  sketch  the  history  and  present  position  of  the  New  J 
York  Academy  of  Medicine,  for  this  we  believe  is  a  fair  reflection  of  the 
best  type  of  medical  enterprise.    The  profession  is  proud  of  the  academy' 
and  asks  that  the  leading  motives  of  medicine  be  judged  by  the  stand- 
ards established  here. 

But  I  have  only  hinted  at  some  of  the  conspicuous  achievements  of 
the  academy  in  order  to  introduce  the  subject  of  this  discourse,  which  is/ 
not  what  estimate  we  place  upon  ourselves,  but  what  conception  the  pub^ 
lie  holds  of  modern  medicine. 

Our  distinguished  president,  in  honoring  me  with  the  task  of  pre- 
paring this  anniversary  address,  has  doubtless  acted  in  accordance  witl 
the  growing  tendency  to  dispense  with  an  orator  and  an  oration  and  toj 
call  on  these  occasions  for  a  specific  treatment  of  some  of  the  many  prob- 
lems that  confront  us.  Being  thus  relieved  of  the  necessity  of  attempt- 
ing a  literary  contribution,  I  have  ventured  to  think  that  the  present! 


THE   PUBLIC   AND    TEE   MEDICAL   PROFESSION  443 

somewhat  delicate  topic  might  well  engage  the  attention  of  this  audience. 
For  there  is  no  denying  the  fact  that  the  iniblic  holds  quite  a  different 
conception  of  medicine  from  that  of  the  physician,  that  there  is  a  grow- 
ing distrust  of  medical  practise  and  an  increasing  dissatisfaction  with 
its  results,  that  disclosures  of  grave  defects  in  the  standards  of  medical 
education,  which  we  freely  admit,  have  mystified  the  public  and  raised  a 
serious  suspicion  regarding  the  general  competency  of  practitioners,  that 
increasing  specialization  and  the  increasing  cost  of  medical  services  are 
misinterpreted,  and,  above  all,  that  the  striking  achievements  of  the  me- 
chanical arts,  the  increase  in  wealth  and  luxurious  living,  have  rendered 
more  conspicuous  than  ever  before  the  uncertain  tenure  of  human  life 
and  the  incompetency  of  modern  medicine  to  control  the  great  majoritv 
of  diseases.  In  the  presence  of  these  obvious  conditions,  which  every 
order  of  intelligence  can  appreciate,  there  is  perhaps  little  wonder  that 
the  public  passes  with  perfunctory  notice  the  brilliant  conquests  of  pre- 
ventive medicine,  ignores  the  rapid  advances  in  the  general  knowledge 
of  biology,  physiology  and  pathology,  and  permits  an  event  like  the  dis- 
covery of  Spirocha'ta  pallida,  an  agent  that  has  had  a  very  profound  in- 
fluence on  human  history,  to  pass  without  even  the  faintest  sign  of  public 
attention. 

It  is  not  intended  to  suggest  that  all  educated  laymen  are  unfamiliar 
with  the  true  progress  and  achievements  of  modern  medicine,  but  it  is 
nevertheless  true  that  prevailing  public  sentiment  is  out  of  touch  and 
out  of  sympathy  with  us.  This  is  seen  in  the  crude  and  halting  manner 
in  which  medical  topics  are  handled  by  distinguished  writers,  clergy- 
men, lawyers,  statesmen  and  public  officials.  It  appears  in  the  garbled 
references  with  which  the  most  inspired  of  the  press  condescend  to  honor 
us  and  misinform  their  readers.  It  shows  in  the  liberal  public  support 
of  all  manner  of  medical  cults,  in  the  wide  extension  of  the  christian 
science  movement,  and  in  the  wavering  front  of  legislation,  which  no 
longer  stands  as  a  firm  defense  of  the  public  health  against  the  depre- 
dations of  irregular  and  incompetent  practitioners  of  medicine.  Even 
the  trustees  of  a  great  university  yield  to  the  allurements  of  a  question- 
able interest,  backed  by  a  paltry  sum,  which  seeks  to  encroach  upon  a 
most  delicate  and  difficult  medical  specialty.  Quite  significant  it  ap- 
pears also  that  the  stage  lends  itself  to  our  disapproval,  by  burlesquing 
the  discovery  of  a  most  notable  and  beneficent  addition  to  modern  thera- 
peutics, and  garnishing  the  entertainment  with  catchy  reference  to  the 


444  MEDICAL   BESEAECE   AND   EDUCATION 

dilemma  which  every  doctor  faces  when  he  charges  a  fee  for  saving  hu- 
man life.  Truly  the  wide  extent  of  this  public  distrust  must  be  ac- 
knowledged, the  grounds  for  it  should  be  carefully  analyzed,  and  we 
must  soberly  ask  the  question.  Is  the  medical  profession  doing  its  full 
duty  to  the  public  ?  James  Eussell  Wallace  once  said,  in  effect,  that  an 
institution  once  established  may  come  to  be  the  chief  obstacle  in  the  way 
of  the  satisfaction  of  the  need  for  which  it  was  established.  Wallace 
made  this  criticism  of  the  church.  Does  it  apply  to  medicine?  Have 
we  stood  too  confidently  on  the  record  of  progress  of  the  last  sixty  years, 
for  modern  medicine  is  only  about  sixty  years  old,  and  failed  to  realize 
that  even  greater  achievements  were  within  our  reach;  have  we  pursued 
science  too  much  for  science'  sake  and  too  little  for  its  influence  on  hu- 
man life;  has  the  old,  almost  sacramental  and  heroic  character  of  med- 
ical service  fallen  before  the  advance  of  commercialism;  is  the  Hippo- 
cratic  oath  still  the  standard  of  medical  ethics ;  is  medical  science,  as  the 
chief  influence  which  makes  for  the  subordination  of  physical  evil,  ac- 
quitting itself  well  in  this  day  and  generation,  or  are  other  sciences  and 
professions  outstripping  us  and  do  we  deserve  the  disaffection  and  diffi- 
dence with  which,  on  the  whole,  public  sentiment  regards  us? 

I  can  only  offer  some  general  considerations  that  bear  upon  these 
broad  topics,  and  in  doing  so  it  is  frankly  acknowledged  that  I  appear 
as  an  advocate  in  defense  of  medicine,  and  even  with  specific  charges  to 
prefer  against  the  public,  and  I  think  this  course  may  be  justified  on  the 
ground  that  good  may  come  from  a  frank  statement  of  what  the  public 
owes  to  the  medical  profession. 

In  the  last  analysis  the  public  disaffection  with  medicine  rests  upon 
an  inherent  defect  of  the  human  mind  which  opposes  correct  thinking 
along  medical  lines.  When  one  reflects  that  even  the  leaders  of  medical 
thought  for  more  than  a  thousand  years  passively  bore  the  yoke  of 
Galen's  crude  conceptions,  of  the  pneuma,  and  the  four  cardinal  prin- 
ciples of  the  body,  blood,  mucus,  yellow  and  black  bile,  conceptions  that 
correspond  to  nothing  of  importance  in  physiology,  and  that  these  con- 
ceptions held  sway  at  the  height  of  the  development  of  Greek  and  Eoman 
literature,  law  and  philosophy,  it  would  seem  that  the  human  mind  is 
constitutionally  unfitted  for  the  grasp  of  biological  principles.  In  this 
quality  the  public  intelligence  of  to-day  has  advanced  but  little  over  the 
standard  of  the  ancients.  Whether  it  be  from  mental  deficiency,  or 
from  a  deeply  rooted  remnant  of  superstition  so  rife  in  all  common 


THE   PUBLIC  AND    THE  MEDICAL   PBOFESSION  445 

people,  or  from  a  possible  narrowing  influence  of  a  portion  of  the 
church,  or  be  it  the  educational  system  of  the  last  centuries  with  its 
schooling  in  rigid  mathematics  and  speculations  in  philosophy,  whatever 
the  cause,  the  modern  mind  is  unfitted  to  grasp  the  idea  of  the  marvel- 
ous delicacy  and  infinite  variations  of  biological  processes,  and,  there- 
fore, it  does  not  understand  medicine. 

Consequently,  throughout  its  entire  history,  medical  science  has  occu- 
pied an  isolated  position  apart  from  the  better  understood  and  more 
cordially  approved  pursuits  of  mankind.  It  was  not  alone  in  punish- 
ment for  his  fatal  results  that  the  medieval  surgeon  had  to  leave  town 
after  each  operation  and  lead  the  life  of  a  nomad.  It  was  a  truthful  ex- 
pression of  the  public  doubt  of  the  honesty  of  the  calling  of  the  surgeon 
and  a  superstitious  fear  that  the  successful  physician  worked  by  super- 
natural methods.  Naturally  the  protection  of  the  church  was  a  ready 
resort  of  the  physician,  and  medicine  and  ecclesiasticism  long  worked  in 
a  certain  harmony,  medicine  always  shielded  by  the  cloak  of  the  priest. 
This  unnatural  union,  enforced  by  public  sentiment,  led  to  the  centuries 
of  reliance  upon  the  healing  power  of  the  saints  and  their  relics,  a  situa- 
tion distinctly  fitting  the  public  taste,  but  it  led  to  the  suppression  of 
rational  thinking  and  experiment,  things  which  did  not  suit  the  public 
taste.  Accordingly  Friedrich  Muller  says  that  "  The  darkest  periods  of 
decay  in  German  medicine  were  those  in  which  philosophical  specula- 
tion and  theological  mysticism  obtained  a  preponderating  influence  over 
medical  problems."  ^  As  degenerative  phases  of  this  movement  we  have 
the  long  history  of  sorcery,  necromancy,  astrology  and  alchemy,  all  of 
which  flourished  in  response  to  the  demand  of  an  uninformed  public 
sentiment.  The  church  has  been  held  responsible  for  much  of  the  sup- 
pression of  medieval  medicine,  but  from  this  point  of  view  it  might 
appear  that  the  public  and  not  the  church  was  essentially  at  fault.  The 
dissection  of  the  human  body,  needless  to  say,  was  distasteful  to  public 
sentiment  and  the  foundations  of  human  anatomy  had  to  be  laid  while 
the  public  were  protesting.  The  antivivisection  movement  throughout 
its  long  history  falls  in  the  same  category  of  public  movements  founded 
on  misconceptions  of  medicine.  The  conflict  between  science  and  re- 
ligion was  another  expression  of  the  same  tendency.  I  believe  that  care- 
ful historical  research  would  reveal  many  familiar  facts  of  history  which 
could  be  cited  and  interpreted  to  show  that  the  public  has  never  under- 
stood its  contemporary  medicine. 

'  Eoyal  Commission  on  University  Education,  June  30,  1911, 


446  MEDICAL   BESEABCH   AND    EDUCATION 

"Would  it  not,  therefore,' be  good  policy  if  the  more  enlightened  pub- 
lic of  to-day  should  analyze  the- grounds  of  its  disaffection  and  make 
sure  that  history  is  not  repeating  itself  and  that  persistent  traces  of  the 
old  prejudice  do  not  lie  at  the  bottom  of  the  current  distrust  of  medical 
institutions  ?  Only  a  few  months  ago  thousands  of  excited  people  gath- 
ered around  the  relics  of  a  departed  saint  in  the  eager  hope  of  receiving 
some  of  their  supposed  healing  virtue.  There  are  many  sides  to  the  sig- 
nificance of  the  christian  science  movement,  as  William  James  has 
shown,  but  so  far  as  it  is  an  intelligible  doctrine,  and  not  mysticism,  it 
rests  chiefly  on  ignorance  and  distrust  of  medical  science.  We  must 
confess  that  the  public  patronage  of  the  numerous  medical  cults  is  log- 
ically due  to  the  failure  of  medicine  to  deal  successfully  with  a  host  of 
minor  ailments.  Physicians  can  well  afford  to  yield  to  osteopaths  and 
hypnotists  the  immediate  concern  with  a  long  list  of  self-limiting  func- 
tional disorders,  but  the  public  can  not  afford  thus  to  intrust  to  any  but 
physicians  the  early  stages  of  serious  disease.  Here  the  public  makes 
the  further  blunder  of  ranking  with  serious  interests  of  medicine  that 
host  of  abnormal  sensations,  some  of  them  painful,  which  fall  to  the 
lot  of  the  overfed  and  the  indolent. 

The  most  familiar  sign  of  the  public  misconception  of  medicine  is 
displayed  in  the  efforts  of  the  daily  press  to  -furnish  information  on 
medical  topics.  With  rare  exceptions  these  efforts  consist  of  sensation- 
alism, personalities,  wonder-tales,  absurdities,  and  a  general  display  of 
the  haste  and  incompetence  of  the  writer.  Every  medical  article  written 
for  the  public  press  should  first  be  submitted  to  a  competent  medical 
expert  for  revision.  More  pernicious  still  is  the  influence  of  a  score  of 
semi-medical  journals  which  cater  to  the  taste  for  misinformation  and 
absorb  a  large  portion  of  the  $50,000,000  paid  annually  in  this  country 
in  the  advertisement  of  quack  medicines. 

The  public  has  heard  that  medicine  is  highly  specialized,  but  has 
not  yet  learned  that  specialization  does  not  immediately  transform  the 
average  general  practitioner  into  a  highly  competent  expert  in  a  nar- 
rower field.  The  clever  law}'er  still  takes  pride  in  demonstrating  that 
the  experienced  manager  of  an  insane  asylum  may  not  be  an  expert  in 
psychiatry.  The  courts  accept  practically  any  holder  of  a  medical  de- 
gree as  a  trustworthy  authority  in  any  department  of  medicine  with 
which  he  chooses  to  claim  acquaintance.  It  is  very  rare  to  find  even  an 
educated  layman  who  understands  that  the  medical  sciences  stand  some- 


THE   PUBLIC   AND    TEE   MEDICAL    PROFESSION  447 

what  apart  from  practise  and  that  they  comprise  a  numerous  group  of 
highly  specialized  branches,  each  requiring  peculiar  training  and  attain- 
ments. For  the  educated  public  the  opinion  of  Eobert  Koch  is  only  in 
a  vague  way  a  little  better  than  that  of  their  family  doctor,  while  the 
uneducated  public  does  not  concern  itself  with  the  opinions  of  scientists. 
Here  is  the  great  dilemma.  Medicine  is  like  the  iceberg,  seven  eighths 
of  which  is  submerged,  but  the  public  must  of  necessity  form  its  esti- 
mate from  the  visible  one  eighth. 

Xot  having  understood  medicine,  public  sentiment  has  never  given 
it  adequate  material  support.  That  support  has  come  from  enlightened 
governments  and  from  men  of  large  means  and  discerning  minds.  The 
numerous  private  endowments  of  medical  philanthropy  and  research  in 
this  and  other  countries  stand  as  a  conspicuous  ornament  in  modern  life. 
Yet  these  gifts  have  come  from  isolated  sources,  they  are  usually  im- 
pelled by  the  occurrence  of  some  tragedy  in  the  family  of  the  donor, 
only  in  a  few  notable  instances  have  they  arisen  from  a  clear  conception 
of  the  needs  and  deserts  of  medicine,  and  they  do  not  constitute  uniform 
and  adequate  public  support.  Even  in  this,  which  is  the  best  expression 
of  the  public  conscience,  too  often  the  institutions  have  been  isolated, 
diminutive  and  ineffective,  and  it  must  be  feared  that  occasionally  they 
have  served  chiefly  to  exploit  the  donor  and  the  donor's  physician.  It  is 
clear  that  the  type  of  almsgiving  counseled  in  the  Sermon  on  the  Mount 
does  not  meet  the  exigencies  of  modern  life.  Medicine  can  not  afford  to 
rely  too  much  on  the  generosity  of  public-spirited  citizens.  It  is,  there- 
fore, a  significant  sign  and  an  honor  to  the  intelligence  of  our  western 
states  that  their  legislatures  have  adopted  the  policy  of  caring  for  med- 
ical education  and  research.  A  considerable  volume  of  public  opinion 
is  back  of  this  policy  and  the  western  people  are  proud  especially  of  the 
assured  future  of  their  universities.  To  what  extent  medicine  will 
flourish  under  these  auspices  remains  to  be  seen,  but  at  present  the  west 
as  well  as  the  east  has  a  wholly  inadequate  idea  of  the  scope  and  cost  of 
medical  education  and  research. 

Perhaps  the  surest  expression  of  public  sentiment  is  found  in  the 
character  of  its  legislation.  I  think  it  must  be  said  that  the  laws  of  the 
land  protect  the  medical  profession  better  than  the  public.  There  has 
been  a  notable  disinclination  to  restrict  the  rights  and  privileges  of  the 
regular  school  of  medicine,  but  there  has  been,  on  the  other  hand,  an 
ill-considered  expansion  of  the  privileges  of  irregular  practitioners  and 


44S  MEDICAL    EESEAECH   AXD    EDUCATIOX 

semi-medical  ciilt^.  In  this  liberality  the  public  sees  only  adherence  to 
our  traditional  ideas  of  freedom,  but  it  does  not  see  at  what  cost  of  life 
it  has  legalized  the  treatment  of  all  sorts  of  disease  and  the  sisrninsr  of 
death  certificates  by  uninstructed  persons. 

In  the  adoption  of  the  measures  which  medical  science  has  demon- 
strated as  necessary  for  the  protection  of  public  health  most  American 
communities  are  delinquent.  There  is  not  a  single  active  school  of  sani- 
tary science  in  the  country,  not  because  the  universities  have  not  tried 
to  establish  them,  but  because  there  is  no  demand  for  them  and  there 
are  no  students.  Therefore,  the  sanitary  laws  of  small  communities  are 
enforced  by  persons  who  are  often  interested  in  their  infraction.  In 
many  cities  typhoid  fever  has  been  epidemic  for  years,  although  these 
communities  were  fully  able  to  build  water  filters.  Medical  science  has 
pointed  the  way  almost  to  the  complete  suppression  of  tuberculosis,  but 
tons  of  tuberculosis  beef  are  marketed  in  Xew  York  daily,  and  the  aver- 
age dairyman  thinks  his  opinion  of  the  tuberculin  test  in  cattle  is  quite 
as  good  as  that  of  the  German  government.  It  is  said  that  the  inhabi- 
tants of  southern  states  ffenerallv  resent  the  ffift  of  a  million  dollars  to 
build  sanitary  waterclosets  and  help  rid  them  of  the  hook-worm.  In- 
deed, it  is  the  usual  experience  for  the  public  to  resist  the  introduction 
of  sanitary  measures,  so  that  it  has  been  necessary  for  medicine  not  only 
to  perfect  these  beneficent  measures,  but  also  to  bind  the  beneficiaries 
hand  and  foot  in  order  to  administer  the  remedy. 

It  is  not  alone  the  pressure  of  politics  or  the  eccentricities  of  the  law 
which  delay  the  formation  of  at  least  one  institute  of  legal  medicine  in 
this  country.  It  is  the  general  failure  to  appreciate  that  a  high  develop- 
ment of  this  branch  of  medicine  is  essential  in  a  well-ordered  commun- 
ity. The  national  government  has  at  last  awakened  to  the  necessity  of 
a  national  bureau  of  health,  such  as  has  long  existed  in  other  civilized 
countries.  Yet  instead  of  going  ahead  with  it  we  have  the  astonishing 
spectacle  of  the  president  of  the  United  States  holding  a  public  hearing 
to  debate  the  question.  Finally  public  sentiment  still  permits  the  health 
commissioner  of  the  state  of  Xew  York  to  be  replaced  every  few  years 
according  to  the  rules  of  political  patronage,  and  with  Asiatic  cholera  at 
OUT  doors  we  have  just  witnessed  the  distinguished  health  ofl&cer  of  the 
port  of  Xew  York  subjected  to  an  investigation  by  a  medically  unin- 
formed jurist  to  whose  mathematical  mind  the  control  of  an  epidemic 
must  be  "'  either  efl&cient  or  inefficient.'" 


TEE   PUBLIC   AND    THE   MEDICAL    PBOFESSIOy  449 

Such  is  a  partial  catalogne  of  the  delinquencies  which  modern  medi- 
cine charges  up  agaLnst  the  modem  public.  In  enumerating  them  I 
fully  realize  that  they  relate  chiefly  to  deep  currents  of  opinion,  thought 
and  custom,  which  move  with  great  momentum  and  are  beyond  the  con- 
trol of  pure  authority.  Yet  they  do  not  concern  isolated  eddies  in  the 
current  of  opinion,  but  fairly  reflect  the  general  tendency  and  color  of 
public  feeling.  Certainly  there  is  here  enough  undig<^ted  food  for 
thought  to  fully  occupy  the  attention  of  the  la}-man  and  to  call  for  a 
concerted  effort  to  render  public  sentiment  more  considerate  of  its  plain 
responsibilities.  To  quote  again  from  Wallace,  "  the  nineteenth  century 
added  to  the  sum  of  human  knowledge  more  than  the  previous  ten,  but 
did  less  than  any  other  to  make  its  knowledge  available  for  human 
needs.'"'  Medicine  has  done  its  duty  to  the  public,  bnt  the  genius  of 
medicine  is  not  understood  and  the  problems  which  medical  K-ienc-e  has 
laid  at  the  door  of  the  modem  world  have  not  been  adequately 
acknowledged. 

There  are  other  duties  besides  those  which  we  are  obliged  and  en- 
abled to  perform  because  of  the  general  progress  of  knowledge.  The 
modem  spirit  of  service  demands  that  medicine  shall  not  over-emphasize 
the  achievements  of  the  past,  but  should  adequately  prepare  for  the  fu- 
ture. The  objects  for  which  this  academy  was  founded  are  just  as 
urgent  to-day  as  in  1847.  The  unification  and  morale  of  the  regular 
profession  rightly  engage  our  constant  attention,  and,  while  we  acknowl- 
edge the  justice  of  outside  criticism  of  the  streaks  of  c-ommercialism 
and  veins  of  mutual  distrust  which  may  afflict  us,  strong  internal  forc-es 
are  at  work  to  combat  these  tendencies.  Xo  commercial  physician  es- 
capes detection  and  the  right  estimate  by  his  fellows,  and  medical  opin- 
ion places  a  far  higher  value  upon  just  valuation  than  upon  clever  criti- 
cism of  the  work  and  attainments  of  ones  c-olleagues. 

Medical  education  is  the  most  earnestly  considered  problem  before 
the  profession  to-day.  The  astonishing  changes  that  have  oc-curred  here 
during  the  last  two  decades  in  America  have  been  approached  in  no 
other  field  of  human  endeavor  and  stand  as  a  monument  to  the  honesty 
and  intellectual  vitality  of  lie  American  medical  profession.  As  a 
feature  in  this  progress  the  fourth  report  of  the  Carnegie  Foundation, 
which  was  delivered  without  fear,  has  dearly  stated  the  situation  and 
hastened  many  desirable  changes.  Incidentally  this  repon  carries  a  mes- 
sage of  great  significance  to  the  public,  since  it  shows  that  the  so-c-alled 

30 


450  MEDICAL   BESEAECH   AND    EDUCATION 

regular  profession  is  the  only  body  seriously  engaged  in  medical  educa- 
tion and  research,  all  the  medical  cults  which  the  public  loves  to  patron- 
ize standing  before  that  bar  of  judgment  empty-handed  or  worse. 

The  third  object  of  this  academy  and  the  duty  of  the  entire  profes- 
sion which  it  represents  is  to  further  the  interests  of  medical  science, 
and  it  remains  as  the  last  part  of  the  plan  of  this  discourse  to  inquire 
whether  we  have  done  our  duty  to  the  ideals  of  medical  science.  In 
making  this  inquiry  we  pass  far  from  the  ground  of  common-sense 
judgments  to  the  field  of  ethical  ideals,  but  a  large  part  of  medicine  lies 
in  this  latter  territory.  In  these  days  when  the  word  research  is  on 
every  man's  tongue,  when  journals  teem  with  titles  purporting  to  relate 
to  new  facts  in  medical  science,  when  the  attention  of  men  of  means  is 
successfully  directed  to  the  results  attainable  in  this  field  of  philan- 
thropy, it  might  seem  to  be  a  difficult  and  useless  task  to  argue  that  the 
medical  profession  does  not  adequately  support  medical  science.  Yet 
this  is  just  the  judgment  which,  with  much  caution  and  reserve,  I 
would  venture  to  maintain  this  evening.  I  hasten  to  acknowledge  the 
brilliant  record  of  American  men  of  science  in  medicine,  the  long  list  of 
notable  discoveries  and  fundamental  contributions  that  represent  the 
best  product  of  American  brains.  As  a  pathologist  I  take  pride  in  be- 
longing to  that  branch  of  the  profession  that  produced  Eicketts  and  a 
score  of  European  martyrs  to  science.  It  is  true  also  that  a  somewhat 
extensive  machinery  has  been  set  in  motion  in  this  country  with  the  idea 
of  enlarging  the  scope  and  raising  the  standard  of  our  scientific  work. 
There  is  much  to  the  credit  side  of  the  account.  Yet  a  clear  conception 
of  the  meaning  of  medical  research,  the  physical  conditions  under  which 
it  can  thrive,  the  organization  of  institutions  that  can  supply  the  train- 
ing and  the  men,  a  true  estimate  of  the  value  of  scientific  attainments 
and  tendencies  in  the  medical  practitioner,  in  fact  a  systematic  atten- 
tion to  the  demands  and  ideals  of  medical  science  are  not  highly  de- 
veloped in  this  country,  and  in  this  respect  medicine,  having  discharged 
its  duty  to  the  public,  is  delinquent  in  its  duty  to  itself. 

Having,  in  a  sense,  closed  the  doors  to  our  public  critics,  I  beg  leave 
to  briefly  state  some  of  the  grounds  on  which  this  feeling  is  based. 

The  misconceptions  of  the  nature  of  medical  research  take  very  nu- 
merous forms.  One  of  the  most  curious  was  embodied  in  a  recent  pub- 
lic document  recommending  the  introduction  of  the  methods  of  the  de- 
partment store  into  scientific  laboratories,  as  though,  as  one  commenta- 


TEE   PUBLIC   AND    THE   MEDICAL    PBOFESSION  451 

tor  retorts,  the  discoveries  of  a  Newton  could  be  called  for  at  a  certain 
day  and  hour,  or  that  the  scientist's  mind  should  run  chiefly  in  the  line 
of  the  card  catalogue  of  trivial  events.     Quite  rife  is  the  idea  tliat  re- 
search consists  in  extracting  the  European  mail,  repeating  the  experi- 
ments one  finds  there,  and  publishing  the  results  without  full  acknowl- 
edgment of  their  inspiration,  or,  what  is  little  better,  with  a  few  addi- 
tional facts  which  are  chiefly  dependent  on  accidental  conditions.    Many 
think  it  necessary  to  point  out  minor  faults  in  fundamental  contribu- 
tions, but  I  very  much  doubt  if  such  activities  are  ever  worth  while. 
To  set  oneself  the  specific  task  of  demolishing  the  conclusions  reached 
by  careful  observations  of  one's  colleagues  is  seldom  a  necessary  step  in 
progress.    Agassiz  advised  "  Study  nature,  not  books."    Some  investiga- 
tors announce  as  many  as  twenty  or  even  thirty  titles  of  original  studies 
in  one  year,  but  Theobald  Smith  said  "the  real  progress  of  medicine  is 
covered  over  with  a  froth  of  research  through  which  only  a  few  great 
minds  are  capable  of  penetrating."    Opinions  differ  as  to  what  methods 
of  announcing  the  progress  of  research  are  consistent  with  sound  judg- 
ment and  a  sterling  devotion  to  the  best  ideals,  but  there  are  those  who 
deplore  the  strife  for  priority,  who  distrust  the  preliminary  communica- 
tion, and  who  believe  that  a  man  is  an  unsafe  man  in  so  far  as  he  is  look- 
ing for  prompt  recognition  of  his  contributions  to  medical  science.     I 
mention  these  somewhat  distasteful  matters  because  the  opportunity  to 
study  carefully  the  mysteries  of  disease  and  to  publish  the  essentially 
new  results  at  the  proper  time  and  in  a  dignified  manner  is  not  so  com- 
mon as  some  of  us  may  believe.    Few  would  care  to  offer  a  definition  of 
genuine  medical  research,  but  I  think  I  see  examples  of  the  true  spirit 
in  men  who  are  very  sensitive  to  the  unknown  in  the  medical  conditions 
they  meet,  who  feel  a  certain  moral  responsibility  toward  the  solution 
of  problems,  and  who  are  willing  to  spend  some  or  all  of  their  time  in 
the  solution  of  these  problems.    This  type  of  research  is  open  to  every 
member  of  the  profession. 

The  discovery  of  Spirocliceta  pallida  was  a  sensational  event,  coming 
apparently  out  of  a  clear  sky.  Yet  even  here  there  were  several  prelim- 
inary steps  which  made  this  discovery  possible.  A  series  of  fundamental 
contributions,  usually  from  many  sources,  almost  always  precedes  a 
great  discovery,  so  that  the  final  step  is  a  perfectly  logical  result  of 
antecedent  factors.  Are  we  not  inclined  to  underestimate  the  value  of 
fundamental  contributions  in  the  haste  to  create  medical  heroes  on  the 


452  MEDICAL   BESEABCH   AND   EDUCATION 

basis  of  supposed  single-handed  discoveries?  Some  find  it  their  func- 
tion to  plant  the  root  of  knowledge  and  cherish  the  growing  tree  over 
many  barren  years,  while  others  delight  to  pluck  the  fruit  when  it  is 
about  ready  to  drop.  It  is  significant  that  the  credit  for  great  steps  in 
the  progress  of  knowledge  can  seldom  be  narrowly  placed. 

The  physical  conditions  that  surround  the  interests  of  medical  sci- 
ence in  this  country  are  comparatively  unpropitious.  When  the  finan- 
cial rewards  of  most  other  lines  in  medicine  are  distinctly  alluring  only 
a  vein  of  eccentricity  or  idealism  can  induce  a  young  man  of  ability  to 
enter  a  career  which  assures  a  comfortable  living  for  but  a  few  fortunate 
leaders.  The  president  of  a  great  university  recently  openly  announced 
that  it  was  necessary  to  fill  the  ranks  of  the  medical  sciences  with  such 
eccentric  persons  who  could  get  along  without  a  decent  living,  and  this 
is  the  tacit  policy  of  all  American  medical  schools.  As  a  necessary  re- 
sult, the  quality  of  brains  that  enters  the  medical  sciences  in  America  is 
of  the  nonconformist  type  and  in  certain  respects  is  inferior  to  that 
which  enters  practical  medicine,  but  I  hasten  to  add  my  belief  that  the 
superior  intellectual  life  and  scientific  methods  of  the  laboratory  may 
enable  the  inferior  man  eventually  to  outstrip  his  more  gifted  colleague. 

In  America  we  boast  of  our  material  resources  for  medical  science, 
but  in  reality  they  are  far  inferior  to  those  available  in  Germany  and 
France.  The  Germans  paid  Waldeyer  140,000  marks  a  year  at  Stras- 
burg,  besides  student  fees,  but  there  are  very  few  positions  in  America 
■which  permit  a  scientist  to  live  in  a  city  house  and  raise  a  family. 
Money  rewards  do  not  attract  the  genuine  investigator,  but  until  the  en- 
dowments of  research  are  on  a  wholly  different  scale  from  the  present 
the  true  possibilities  of  American  medical  science  will  not  be  realized. 

The  organization  of  our  medical  institutions  could  hardly  be  worse 
for  the  progress  of  science.  The  three  main  activities,  the  care  of  the 
sick,  the  education  of  physicians,  and  the  search  for  new  facts,  have 
grown  up  in  isolation,  although  every  one  recognizes  that  each  is 
dwarfed  without  the  others.  The  complex  factors  which  stand  in  the 
way  of  successful  reorganization  have  been  clearly  stated  by  recent 
writers  and  the  public  conscience  is  slowly  awakening.  The  medical 
schools  are  beginning  to  see  that  they  are  quite  as  much  responsible  to 
medical  science  as  to  medical  education,  and  at  least  one  school  is  being 
founded  with  this  responsibility  chiefly  in  view.  It  becomes  increasingly 
difficult  for  the  busy  practitioner  to  meet  the  demands  of  a  great  depart- 


TEE   PUBLIC   AND    THE   MEDICAL   PEOFESSION  453 

ment  in  a  university,  but  he  can  perform  an  honorable  service  by  sur- 
rounding himself  with  young  men  who  have  been  trained  in  the  sciences 
upon  which  his  specialty  depends  for  progress.  The  time  has  come  when 
those  who  aspire  to  a  university  career  or  distinction  of  any  kind  in  the 
clinical  branches  must  serve  an  apprenticeship  in  the  medical  sciences 
instead  of  in  the  personal  service  of  the  influential  doctor. 

The  interests  of  medical  education  are  in  the  hands  of  several  very 
able  bodies  and  its  innumerable  and  very  complex  problems  have  been 
discussed  with  much  care  and  discernment.  Yet  I  believe  that  the 
trend  of  this  discussion  indicates  that  the  American  profession  under- 
estimates the  claims  of  medical  science  as  an  ideal  in  education.  Every- 
thing is  being  swept  aside  in  the  effort  to  provide  the  student  with  pre- 
mature clinical  experience.  We  shall  doubtless  turn  out  the  most  adept 
practitioners  in  the  world,  as  we  do  dentists,  but  dentistry  is  almost 
sterile  as  a  science  and  relies  on  medicine  for  its  chief  progress.  It  is  to 
be  feared  that  the  new  curricula  discriminate  too  boldly  against  that 
broad  acquaintance  with  the  medical  sciences  which  alone  can  maintain 
the  standards  of  the  profession.  We  discriminate  against  knowledge 
more  than  Germany  undervalues  practical  ability.  We  are  not  yet  will- 
ing to  pay  the  price  of  mature  and  effective  clinical  instruction,  for  that 
price  is  a  fifth  year  in  the  medical  curriculum. 

In  the  years  1800-1810,  or  longer,  a  leading  hospital  in  New  York 
devoted  funds  to  the  purchase  of  expensive  medical  books  and  main- 
tained a  library  for  the  use  of  its  staff.  The  trustees  seemed  to  feel  a  re- 
sponsibility to  medical  science.  That  library  has  been  dissipated  and 
the  hospital  is  now  run  on  strictly  business  principles.  Yet  there  is  ven- 
erable precedent  for  the  support  of  medical  science  by  our  great  hos- 
pital endowments,  and  it  has  been  made  clear  to  the  slumbering  con- 
science of  the  hospital  trustee  that  he  has  long  been  gravely  delinquent 
in  an  important  duty.  It  will  be  a  notable  event  in  the  history  of  Amer- 
ican medicine  when  that  conscience  is  fully  roused  to  action  and  when, 
overcoming  every  obstacle,  there  is  effective  cooperation  between  the  im- 
mense resources  of  our  hospitals  and  those  of  the  universities. 

That  there  are  contrary  opinions  regarding  the  value  of  scientific 
training  to  the  practitioner  merely  shows  how  vague  is  the  general  con- 
ception of  laboratory  science.  It  seems  to  me  that  this  is  the  most  dis- 
couraging side  of  the  present  outlook  for  medicine.  It  is  chiefly  re- 
sponsible for  the  gulf  which  separates  medical  science  from  medical 


454  MEDICAL    EESEABCH   AND    EDUCATION 

practise,  and  it  accounts  for  a  vast  number  of  the  occasions  when  the 
right  thing  is  not  done  at  the  right  time  at  the  bedside.  It  substitutes 
empiricism  for  carefully  tested  opinion.  Not  being  familiar  with  the 
methods  and  limitations  of  laboratory  technique,  the  practitioner  readily 
acquires  a  confidence  in  the  infallibility  of  diagnostic  tests,  of  which  the 
dead  far  outnumber  the  living.  Or  he  affects  complete  distrust  of  the 
whole  field  of  microscopical  and  chemical  diagnosis.  It  remains  the 
great  function  of  the  clinical  observer  to  discern  many  of  the  problems 
of  medicine  and  to  suggest  to  the  laboratory  those  that  may  be  solvable, 
but  this  function  can  be  performed  only  by  one  who  is  acquainted  with 
the  methods  and  capacities  of  laboratory  science.  Scientific  training 
adds  class  to  the  quality  of  a  medical  practitioner,  and  whether  we  like 
it  or  not  it  is  a  fact  that  the  well-trained  man  is  the  productive  man  in 
his  field  and  is  steadily  replacing  the  untrained.  Competition  in  clin- 
ical preferment  has  not  yet  reached  with  us  the  stage  when  a  record  of 
productive  work  is  essential,  but  that  day  is  not  far  distant,  and  I  ven- 
ture to  predict  that  it  will  come  suddenly  and  to  the  sore  discomfiture 
of  many  of  the  confident  detractors  of  the  value  of  laboratory  training 
to  the  practitioner. 

Thus  several  of  the  most  vital  interests  of  medical  science  suffer  from 
very  conspicuous  defects  in  the  present  support- and  even  in  the  future 
plans  of  the  profession.  It  is  not  too  much  to  say  that  medical  science 
flourishes  with  us  in  the  face  of  unnatural  hindrances,  many  of  which 
it  is  within  the  power  of  the  profession  to  mitigate  or  relieve.  Some  of 
the  conditions  would  not  be  tolerated  for  a  moment  in  the  industrial 
world,  and  others,  such  as  the  obstacles  to  the  scientific  development  of 
our  hospitals,  are  incompatible  with  a  plain  sense  of  honor.  In  certain 
aspects,  as  Wallace  suspected  of  the  church,  the  inertia  of  our  medical 
institutions  and  traditions  stands  in  the  way  of  the  satisfaction  of  med- 
ical needs.  I  venture  to  say  that  the  settled  policy  of  this  academy 
should  involve  a  systematic  campaign  in  support  of  the  larger  interests 
of  medical  science.  Twenty  years  ago  Max  IsTordau  predicted  that  in  a 
quarter  of  a  century  American  medicine  would  outstrip  the  world.  I 
fear  he  is  disappointed.  We  began  too  late  and  there  are  only  five  years 
left.  Yet  five  years  of  the  right  kind  of  effort  would  make  a  vast  dif- 
ference in  the  complexion  of  medical  institutions  in  America. 

And  finally,  may  we  not  anticipate  some  of  the  rewards  of  faithful 
devotion  to  the  ideals  of  medical  science  ?    We  love  to  dwell  on  the  past 


THE   PUBLIC   AND    THE   MEDICAL    PEOFESSION  455 

conquests  of  medicine,  in  the  control  of  epidemics,  in  the  rendering 
habitable  of  the  uttermost  parts  of  the  earth  and  the  slums  of  great  cities, 
in  the  triumphs  of  surgery  on  which  we  drill  the  public,  in  the  immense 
advances  in  chemistry,  physiolog}'  and  pathology,  and  in  the  creation  of 
many  new  branches  of  medical  science,  all  of  which  have  combined  to 
add  twenty  to  twenty-five  3'ears  to  the  average  tenure  of  human  life,  but 
one  may  listen  to  this  rehearsal  without  a  particle  of  emotion  when  one 
considers  the  greater  problems  that  still  confront  us.  The  fruits  of  the 
germ  theory  have  enabled  us  to  prevent  infectious  diseases,  but  our  ca- 
pacity to  cure  them  is  extremely  limited.  In  the  knowledge  of  diseases 
of  nutrition  and  metabolism  hardly  a  beginning  has  been  made.  Of  the 
ultimate  nature  of  the  physical  and  chemical  processes  upon  which  life 
and  animal  functions  depend  we  possess  only  vague  surmises.  Before 
the  long  list  of  natural  diseases  of  the  animal  kingdom  we  stand  as  help- 
less catalogers  of  superficial  phenomena.  Medicine  is  still  in  its  infancy. 
Comparative  medicine  is  a  pigmy  opposed  to  a  colossus  of  unmeasured 
proportions.  Considering  the  vast  scope  of  its  problems,  the  activities 
of  our  anti-cruelty  societies,  which  are  the  pride  of  many,  appear  as  idle 
splashings  on  the  water's  edge  of  the  ocean  of  animal  suffering,  while 
the  real  depths  of  that  ocean  are  being  sounded  by  the  workers  in  com- 
parative pathology.  One  can  review  only  with  horror  the  brutal  forms 
of  parasitism  and  the  merciless  laws  of  natural  slaughter  and  death  that 
prevail  among  the  lower  animals.  It  was  an  observation  in  natural  his- 
tory when  Isaiah  said,  "  They  shall  look  unto  the  earth  and  find  dark- 
ness, dimness  of  anguish."  For  we  are  charged  with  the  whole  task  of 
mitigating  physical  evil  throughout  the  entire  animal  kingdom,  and  our 
human  interests,  as  we  are  beginning  to  see,  are  inextricably  bound  up 
with  those  of  the  lower  animals.  We  must  accept  the  hope  that  nature 
herself  shall  some  day  be  redeemed.  Medicine  is  clearly  marked  as  the 
chief  instrument  in  that  redemption  and  only  in  the  light  of  this  destiny 
can  her  true  dignity  be  realized.  How  then  can  we  rest,  even  for  a  mo- 
ment, on  the  achievements  of  the  past  ? 

Every  period  in  the  progress  of  medicine  is  marked  by  opportunities 
which  render  it  more  significant  than  its  predecessors.  At  the  present 
time,  while  no  new  era  in  medicine  seems  imminent,  the  opportunity  for 
the  successful  application  of  known  principles  to  practical  questions  is 
unprecedented.  No  medical  heroes  rule  with  unquestioned  authority  to 
limit  the  freedom  of  thought  and  action  of  the  host  of  competent  work- 


456  MEDICAL   BESEABCH   AND   EDUCATION 

ers  in  every  land.  The  original  germ  theory  has  served  its  purpose  well 
and  descriptive  bacteriology  is  being  succeeded  by  the  study  of  the  con- 
tributing causes  of  bacterial  diseases  and  of  the  factors  which  control 
the  incidence  and  distribution  of  microorganisms.  The  doctrine  of 
anaphylaxis,  or  increased  and  specific  susceptibility  to  the  action  of 
chemical  agents,  promises  to  carry  us  far  more  deeply  into  the  mysteries 
of  disease  than  any  previous  contribution  to  pathology.  The  application 
of  known  medical  principles  to  problems  in  sociology  and  in  the  preven- 
tion of  chronic  and  hereditary  diseases  offers  an  immense  field  for  the  fu- 
ture activities  of  medicine.  The  great  significance  of  the  organs  of  in- 
ternal secretion  is  being  more  clearly  recognized  and  the  revolutionary 
influence  which  this  department  of  physiology  seems  likely  to  have  upon 
the  medicine  of  the  future  is  in  no  sense  belittled  by  the  imperfections 
of  our  present  knowledge.  The  science  of  nutrition  seems  to  have  en- 
tered upon  an  era  of  permanent  progress,  based  upon  the  carefully  at- 
tested data  of  the  physiological  chemist.  The  last  decade  has  seen  the 
science  of  eugenics  take  definite  form,  that  science  of  the  future  which 
looks  toward  the  day  when  every  child  born  can  be  assured  of  a  sound 
mind  in  a  sound  body.  Experimental  morphology  and  the  studies  of 
heredity  warrant  great  hopes  in  this  untrodden  territory. 

No  one  would  prophesy  which  fields  may  prove  most  quickly  produc- 
tive, for  all  our  problems  are  eventually  solvable  and  time  is  of  minor 
consequence  before  the  steady  advance  of  experimental  science,  that  in- 
strument to  the  power  of  which  Pasteur  saw  no  limitations.  History 
justifies  the  fullest  scope  to  the  scientific  imagination,  for  the  miracles 
of  yesterday  are  the  commonplaces  of  to-day.  It  is  a  grave  duty  and  a 
high  privilege  for  every  physician  to  see  that  his  influence,  in  whatever 
capacity,  tells  for  the  realization  of  the  ideals  of  medical  science.  For 
we  look  for  the  day  when  the  cry  of  the  innocent  victim  of  disease,  be  he 
man  or  beast,  shall  be  answered,  and  when  the  maladjustments  of  a 
vicious  nature  shall  be  coerced  and  corrected  by  human  intelligence. 


THE  DUTIES  AXD  EESPOXSIBILITIES  OF  TRUSTEES  OF 
PUBLIC  MEDICAL  INSTITUTIONS^ 

By  W.  W.  Keen,  M.D.,  LL.D., 

Emeritus  Professor  op  Sitrgert,  Jefferson  Medical  College 

The  value  of  occasional  and  stated  gatherings  of  the  principal 
leaders  of  medical  thought  in  the  various  special  departments  is 
acknowledged  by  all.  Certainly  those  who  have  attended  this  congress, 
now  held  for  the  sixth  time,  have  felt  its  broadening  influence.  We  are 
apt  to  become  narrow  when  we  are  devoted  heart  and  soul  to  one 
specialty,  be  it  medicine,  surgery,  physiology,  ophthalmology,  or  any 
other.  When  we  meet  nearly  all  of  the  more  prominent  men  in  cognate 
and  interrelated  branches  of  medicine  in  Washington  every  third  year, 
we  are  sure  to  find  that  there  are  as  interesting  and  as  important 
questions  in  other  specialties  as  there  are  in  our  own;  and,  moreover, 
we  are  sure  to  find  that  there  are  men  of  as  acute  intelligence,  wide  read- 
ing, and  original  thought  in  other  than  our  own  departments  whom  it  is 
our  pleasure  to  meet,  and  whose  acquaintance  becomes  not  only  valu- 
able for  what  we  find  them  to  be,  but  because  of  the  stimulus  that  they 
give  to  our  own  thoughts. 

Ordinarily  the  presidential  address  has  been  devoted  to  some  special 
professional  topic.  My  first  idea  was  to  select  such  a  subject  for  to- 
night, but  as  I  was  in  India  when  I  received  the  very  highly  appreciated 
notice  of  my  election  as  President  I  asked  the  members  of  the  Executive 
Committee  for  suggestions,  being  sure  that  their  united  judgment  would 
be  better  than  my  own.  I  was  very  glad  when  they  proposed  the  topic 
upon  which  I  shall  address  you,  partly  because  it  is  different  from  the 
usual  type  of  such  addresses,  and  partly  because  it  seems  to  me  appro- 
priate to  the  present  time.  I  shall,  therefore,  give  the  time  at  my  dis- 
posal to  presenting  to  you  some  thoughts  on  "The  Duties  and  Ee- 
sponsibilities  of  Trustees  of  Public  Medical  Institutions." 

^The  Presidential  Address  at  the  Sixth  Congress  of  American  Physicians 
and  Surgeons,  Washington,  May  12,  1903.  Published  in  the  Transactions  of  the 
Congress  of  American  Physicians  and  Surgeons,  1903.  [I  have  put  brackets  to 
the  footnotes  now  added  to  show  that  they  did  not  appear  in  the  original 
address. — ^W.  W.  Keen.] 

457 


458  MEDICAL    BESEAECE    AND    EDUCATION 

Before  entering  upon  my  topic  I  beg  to  state  explicitly  that  what  I 
will  say  is  offered  in  no  spirit  of  unfriendly  criticism,  but  only  by  way 
of  friendly  suggestion.  I  have  been  too  long  and  too  intimately  asso- 
ciated with  scores  of  such  trustees  not  to  know  that  they  are  almost 
without  exception  generous,  self-sacrificing,  giving  of  their  time  and 
money  and  thoughtful  care  without  stint,  and  often  sacrificing  personal 
convenience  and  comfort  for  the  good  of  the  college  or  hospital  which 
they  so  faithfully  serve.  Anxious  to  discharge  their  trust  to  the  best 
of  their  ability,  I  am  sure  they  will  accept  these  suggestions,  the  fruit 
of  forty  years  of  personal  service  as  a  teacher  and  a  hospital  surgeon, 
in  the  same  friendly  spirit  in  which  they  are  offered. 

There  are  two  such  classes  of  institutions  to  be  considered:  (1)  Medi- 
cal colleges  and  (2)  hospitals,  whether  they  be  connected  with  medical 
schools  or  not. 

There  is,  it  is  true,  a  third  class  of  trustees  for  a  wholly  new  kind  of 
medical  institution  which  has  arisen  as  a  modern  Minerva  Medica,  born 
full-armed  for  the  fray.  Of  this  class  we  have  as  yet  but  a  single 
example — the  Rockefeller  Institute  for  Medical  Eesearch.^  Akin  to  it 
are  laboratories  for  special  investigations,  such  as  the  two  cancer  labora- 
tories in  Buffalo  and  Boston.^  But  the  Eockefeller  Institute  is  so  re- 
cent, and  its  scope  at  present  necessarily  so  undetermined,  that  I  would 
not  venture  to  consider  the  duties  of  these  tnistees,  and  I  am  sure  their 
responsibilities  are  adequately  felt  by  them.  Moreover,  their  admi- 
rable selection  of  a  Director  for  the  institution  is  the  best  pledge  of  a 
future  wise  administration.  I  heartily  congratulate  the  profession  and 
America  upon  the  establishment  of  so  peculiarly  useful  an  Institute. 
Its  founder  has  wisely  left  its  work  unhampered  saving  as  to  its  general 
purpose,  and  the  whole  world,  and  especially  the  United  States,  will 
soon  be  his  debtor  for  researches  and  discoveries  that  will  abridge  or 
even  abolish  some  diseases,  shorten  sickness,  prolong  life,  and  add 
enormously  to  the  sum  of  human  happiness.  Could  any  man  of  wealth 
by  any  possible  gift  win  for  himself  a  higher  reward  or  a  happier  recol- 
lection when  he  faces  the  future  world?* 

Though  not  a  medical  institution,  I  can  not  refrain  also  at  this  point 
from  expressing  not  only  for  myself,  but  for  you,  our  hearty  apprecia- 

*  [The  Memorial  Institute  for  Infectious  Diseases  in  Chicago  had  just  been 
founded.] 

'  [Other  similar  laboratories  have  since  been  established.] 

■*  [How  completely  and  how  splendidly  this  prediction  has  been  fulfilled!] 


PUBLIC    MEDICAL    INSTITUTIONS  459 

tion  of  what  the  Carnegie  Institution  has  done  for  medicine  in  the 
reestablishment  of  the  "Index  Medicus."  This  publication  is  essen- 
tially and  peculiarly  American  in  origin,  but  its  usefulness  is  world- 
wide. It  aids  alike  an  author  in  Japan,  or  in  India,  in  Europe  or 
America.  It  is  one  of  the  best  and  wisest  undertakings  of  this  lusty 
educational  giant.  But  to  ensure  the  permanent  publication  of  the 
"  Index  Medicus  "  the  profession  must  show  that  it  really  values  this 
generous  gift.  Unless  the  "Index"  finds  a  hearty  support  in  the  pro- 
fession abroad  and  especially  at  home,  we  can  hardly  expect  the  con- 
tinuance of  this  unique  and  invaluable  publication.  May  I  earnestly 
ask,  therefore,  of  this  audience  of  the  chief  medical  authors  of  the 
United  States  that  each  one  will  demonstrate  his  appreciation  by  an 
immediate  subscription  to  the  "  Index  Medicus." 

There  are  some  matters  common  to  both  the  medical  college  and  the 
hospital  which  may  be  considered  together.  The  most  important  of  all 
these  is  the  cordial  and  hearty  cooperation  of  the  medical  men  connected 
with  the  college  or  hospital  and  the  boards  of  trustees.  In  order  to 
ensure  this  the  members  of  each  body  must  be  acquainted  with  each 
other.  I  have  known  of  instances  in  which,  if  a  professor  in  the  medical 
school  ventured  to  suggest  any  changes  as  to  its  management,  or  even 
to  state  his  opinion  as  to  the  qualifications  of  a  candidate  for  a  vacant 
professorship,  his  suggestions  were  resented  as  an  interference,  instead 
of  being  welcomed  as  a  means  of  valuable  information.  I  take  it  for 
granted  that  we  should  not  ofEer  such  suggestions  after  the  fashion  of 
a  partisan  either  of  a  man  or  a  measure,  for  the  advancement  of  a 
friend  or  to  the  disadvantage  of  an  enemy,  but  solely  for  the  good  of  the 
institution  with  which  we  are  connected.  He  who  would  endeavor  to 
foist  a  friend  upon  an  institution  became  he  is  his  friend,  and  in  spite 
of  the  fact  that  a  rival  is  the  abler  man,  and  better  fitted  for  the  position, 
is  just  as  false  to  his  duty,  to  his  college,  or  to  his  hospital  as  the 
trustee  who  would  vote  for  the  less  desirable  man  on  the  ground  of 
personal  friendship  or  of  association  in  some  society,  church  or  other 
similar  body.  Of  all  these  influences,  that  arising  from  membership  in 
the  same  religious  body  is,  I  fear,  the  most  frequent  and  yet  most  abso- 
lutely indefensible.  What  one's  theological  opinions  are  has  no  more  to 
do  with  one's  qualifications  for  a  professional  or  hospital  appointment 
than  his  opinions  on  protection  as  against  free  trade,  or  whether  Bacon 
or  Shakespeare  wrote  Hamlet. 


460  MEDICAL   BESEABCH   AND    EDUCATION 

I  have  always  honored  one  of  a  board  of  trustees,  who  was  an  old 
personal  friend  of  my  father's  and  who  had  known  me  from  boyhood, 
yet  who  in  my  early  professional  career,  when  I  asked  for  his  vote  for 
an  important  hospital  appointment,  had  the  manly  courage  to  tell  me 
that  he  thought  a  rival,  who  was  older  and  more  experienced,  was  the 
better  man  for  the  place  and  that  he  should,  accordingly,  vote  for  him, 
and  not  for  me.  I  confess  it  was  at  the  time  a  bitter  disappointment 
to  me,  but  I  never  had  so  high  an  opinion  of  my  father's  friend  as  after 
he  denied  me  his  vote  and  I  lost  the  appointment. 

There  should  be,  in  my  opinion,  but  two  questions  asked  in  con- 
sidering the  election  of  either  a  professor  or  a  hospital  physician  or 
surgeon.  First,  which  one  of  the  candidates  for  the  place  has  the  best 
qualifications  from  the  medical  point  of  view?  This  should  include 
not  only  his  scientific  knowledge,  but  his  ability  practically  to  impart  or 
to  apply  that  knowledge.  Secondly,  are  his  personal  qualifications  and 
character  such  as  to  make  him  a  desirable  incumbent  of  the  position? 
It  must  be  remembered  that  a  man  may  be  scientifically  and  practically 
an  extremely  able  man,  but  of  such  a  quarrelsome  disposition,  or  the 
unfortunate  possessor  of  some  other  similar  personal  disqualification,  as 
to  make  him  a  most  undesirable  member  of  a  staff.  The  personal  equa- 
tion may  be  quite  as  important  as  the  scientific  qualification.  Of  course, 
his  personal  moral  character  should  be  above  reproach.  To  place  a 
drunkard  or  a  libertine  in  a  position  of  so  much  responsibility  and  in- 
fluence is  to  abuse  a  trust.  ISTo  patient  should  be  confided  to  the  care 
of  such  a  man,  and  still  more  no  such  man  should  be  made  an  instructor 
of  young  men,  upon  whom  his  influence  would  be  most  disastrous. 

It  is  often  extremely  difiicult  for  a  layman  to  reach  a  correct  con- 
clusion as  to  the  qualifications  of  medical  men  for  college  or  hospital 
appointments,  because  of  the  confident,  yet  conflicting,  statements  of 
their  friends.  But  there  is  apt  to  be  a  certain  clear  partisanship  in 
such  statements  which  betrays  the  purpose  of  the  speaker.  Especially 
will  this  be  so  if  he  advocates  the  election  of  A  or  B  on  the  lower 
grounds  of  friendship,  social  position,  or  for  other  similar  motives. 
The  man  who  is  advocating  the  best  man  because  he  is  the  best  man  has 
the  stamp  of  sincerity  upon  every  word. 

Perhaps  the  most  striking  example  I  can  adduce  of  such  an  un- 
fortunate misjudgment  is  Dr.  S.  Weir  Mitchell,  who  was  denied  a 
professorship  in  both  the  medical  institutions  of  his  native  city,  thus 


PUBLIC   MEDICAL   INSTITUTIONS  461 

depriving  them  of  the  most  brilliant  medical  genius  that  America  has 
produced  within  my  personal  recollection.  For  him  it  is  now  a  matter 
of  indifference,  and  for  American  literature  it  has  been  a  gain.  But 
for  medicine,  and  especially  for  physiolog}',  it  was  an  immense  loss. 
Both  of  his  rivals  were  estimable,  worthy  gentlemen  who  held  an 
honorable  position  in  the  profession,  it  is  true,  but  Mitchell  is  a  genius. 
"  Eclipse  was  first ;  the  rest  were  nowhere." 

One  of  the  best  methods  of  bringing  the  medical  board  and  the 
board  of  trustees  into  more  intimate  contact  would  be  to  have  the  dean 
or  a  committee  of  the  faculty,  or,  in  a  hospital,  if  the  staff  is  not  too 
large,  the  whole  staff  invited  to  the  meetings  of  the  board.  Here  I  can 
speak  from  personal  experience.  At  the  Orthopedic  Hospital  and  In- 
firmary for  Nervous  Diseases  in  Philadelphia  there  are  three  surgeons 
and  three  physicians.  These  members  of  the  medical  staff  are  invited 
to  meet  with  the  board  of  managers  at  each  monthly  meeting,  excepting 
the  annual  meeting,  when  the  medical  staff  is  elected.  They  are  free 
to  express  their  opinions  on  any  topic  relating  to  the  management  of 
the  hospital  to  which  their  judgment  may  contribute  something  of 
value,  but  when  a  decision  is  taken  they  have  no  vote.  It  is  purely  in 
an  advisory  capacity  and  for  the  purpose  of  giving  and  receiving  in- 
formation that  they  are  present.  The  plan  works  exceedingly  well. 
When  economy  is  necessary  in  the  hospital,  the  staff  is  fully  acquainted 
with  the  fact  and  can  cooperate  with  the  trustees;  when  expenses  have 
run  up  from  carelessness  in  the  wasteful  use  of  dressings  or  applicances, 
a  halt  is  called ;  when,  alas,  very  rarely,  the  treasurer  is  all  smiles,  and 
plans  for  the  extension  of  the  hospital,  or  the  installation  of  some  new 
addition  to  the  plant  is  contemplated,  their  knowledge  as  to  the  neces- 
sity, for  instance,  of  a  hydrotherapeutic  or  an  .f-ray  plant,  or  a  new 
operating-room,  is  of  the  greatest  possible  value.  Nothing  but  good,  in 
my  opinion,  can  come  from  such  personal  cooperation. 

One  of  the  difficult  questions  which  boards  of  trustees  have  to  face  is 
whether  there  shall  be  a  fixed  age  at  which  a  college  professor  or  a 
hospital  physician  or  surgeon  shall  retire  from  the  active  duties  of  his 
post.  I  firmly  believe  that  they  should  fix  such  a  retiring  age  in  the 
interest  of  the  students  and  of  the  patients.  As  age  advances,  a  man's 
opinions  and  his  practise  become  "  as  petrified  as  his  arteries."  He  is 
incapable  of  constant  study,  of  adding  to  his  knowledge  or  of  keeping 
up  with  the  feverish  strides  of  medicine.     He  ought  then  to  be  relieved 


462  MEDICAL   BE  SEARCH   AND    EDUCATION 

of  his  cares  and  his  duties.  If  no  rule  exists,  he  is  allowed  to  continue 
his  ineiBcient  or  even  disastrous  work,  or  by  some  harsh  suggestion  is 
compelled  to  give  place  to  another  more  competent  man.  A  rule  is  a 
condition  accepted  when  he  is  appointed.  In  the  army  and  navy,  when 
an  officer  reaches  64  or  62  years  of  age  he  is  retired  on  reduced  pay,  and 
because  it  is  a  rule  he  does  not  feel  hurt  or  humiliated.  So  in  a  college 
or  a  hospital,  when  time  and  the  rule  bring  us  to  the  period  when  we 
must  gracefully  retire,  no  one's  reputation  is  injured  or  his  feelings 
lacerated. 

I  have  ascertained  that  the  following  rules  are  in  force  in  some  of 
the  larger  institutions : 

At  Harvard,  the  age  when  a  professor  may  request  to  be  retired  is 
60,  provided  he  has  been  in  the  service  of  the  university  for  20  years, 
with  a  reduced  pay  ranging  from  one  third  to  two  thirds  of  his  salary. 
At  66  he  may  be  retired  by  the  President  and  Fellows  partly  or  wholly. 
The  details  of  the  plan  are  admirably  arranged. 

At  Chicago,  while  no  plan  is  yet  in  force,  largely,  I  presume,  be- 
cause of  its  recent  establislmient  on  the  present  basis,  such  a  plan  will 
soon  be  made  operative. 

At  Columbia  the  retiring  age,  after  15  years  of  service,  is  65,  either 
at  the  request  of  the  professor  or  upon  motion  of  the  trustees,  and  on 
half-pay. 

At  Yale  the  retiring  age  is  65,  after  25  years  of  service,  and  on 
half-pay,  but  the  retirement  is  not  compulsory.  It  will  probably  be  made 
compulsory  before  long. 

At  Cornell  the  retiring  age  is  70,  but  the  pension  fund  will  not  be 
available  until  1914.     The  retiring  pension  will  then  be  $1,500,^ 

At  the  University  of  Pennsylvania  and  at  Johns  Hopkins  no  retiring 
age  is  fixed. 

The  only  hospitals  I  know  of  in  which  a  retiring  age  is  fixed  are  the 
Massachusetts  General  Hospital  and  the  Boston  City  Hospital.  At  the 
former  the  compulsory  retiring  age  of  the  siirgeons  is  63,  and  of  the 
physicians,  65.  At  the  Boston  City  Hospital  the  visiting  surgeons  are 
retired  at  65,  but  the  physicians,  gynecologists  and  all  the  other  medical 
officers  continue  in  service  indefinitely — a  very  curious  anomaly. 

These  varying,  but  in  the  main  identical,  provisions,  when  any  exist, 

°  [The  establishment  of  the  Carnegie  Foundation  for  the  Advancement  of 
Teaching  with  its  rules  for  pensions  has  altered  most  of  these  conditions.] 


PUBLIC   MEDICAL   INSTITUTIONS  463 

show  the  trend  of  thought  and  practice.  They  geneially  apply  to  the 
medical  department,  except  that,  in  case  a  professor  is  engaged  in  the 
practise  of  his  profession  and  so  has  a  private  income,  the  provision  for 
continuing  a  portion  of  his  salary  does  not  apply.  This  is  right  and 
fair.  Of  course,  in  all  hospitals  in  which  there  are  no  salaries,  no 
provision  as  to  reduced  salary  would  obtain. 

The  point  I  wish  to  emphasize  is,  however,  that  the  age  limit  (which 
in  my  opinion  should  be  65)  should  be  compulsory  and  so  not  be 
invidious  in  any  given  case.  It  will  be  objected  that  not  a  few  men 
are  in  full  intellectual  and  physical  vigor  at  65,  and  it  will  be  a  detri- 
ment to  the  institution  to  lose  their  services  when  their  ripe  experience 
and  admirable  teaching  are  most  desirable.  I  admit  it.  But  for  every 
one  such  case  of  harm  done  by  compelling  a  competent  man  to  stop, 
there  are  a  score  of  instances  of  men  who  are  doing  vast  injury  by  their 
inefficiency.  Moreover,  in  the  very  few  cases  in  which  it  might  be 
allowable,  as  boards  of  trustees  make  rules  they  can  unmake  them,  and 
in  special  cases  they  could  pay  a  graceful  compliment  and  preserve  to 
the  institution  their  exceptional  men  by  extending  the  limit  to  70.  In 
no  case  should  I  think  it  wise  to  go  beyond  this  limit. 

In  some  of  the  universities  I  have  quoted  a  sabbatical  year  of  rest 
or  study  is  allowed  a  professor.  He  is  put  upon  half-pay,  and  his  place 
is  filled  by  a  temporary  substitute,  who  receives  the  other  half  of  his 
salary.  I  believe  that  in  present  conditions  this  should  not  be  applied 
to  medical  faculties,  for  nearly  all  of  the  professors  are  in  active  practise 
and  take  sufficiently  long  summer  holidays.  These  latter  are  often 
spent  in  observation  and  study  abroad — a  most  useful  and  remunerative 
employment  of  a  holiday — and  serve  the  purpose  of  the  sabbatical  year 
for  men  whose  entire  time  is  given  to  their  teaching.  In  hospitals  it 
certainly  should  not  apply. 

One  of  the  recurring  questions  in  hospital  and  college  management 
is  whether  there  should  be  a  certain  number  of  doctors  on  the  board 
of  trustees.  I  know  that  there  is  a  wide  diversity  of  opinion  upon  this 
point.  My  own  belief  is  that  a  small  proportion  of  well-chosen  medical 
men  is  a  distinct  advantage  on  such  boards.  I  have  said  a  "small 
proportion,"  for  it  should  not  be,  I  think,  larger  than  probably  20  per 
cent.;  and  I  also  said  "well  chosen";  that  is,  they  should  be  men  of 
large  mental  caliber  and  executive  ability.  It  should  be  distinctly 
understood,  if  not  indeed  absolutely  expressed,  in  institutions  in  large 


464  MEDICAL   BESEABCH   AND   EDUCATION 

cities  at  least,  that  any  physician  or  surgeon  placed  upon  such  a  board 
should  never  be  eligible,  even  by  resignation  from  the  board,  for  a  posi- 
tion on  the  faculty  or  the  medical  staff.  In  small  towns  the  lack  of 
suitable  persons  for  hospital  trustees  and  members  of  the  hospital  staff 
might  make  it  desirable  not  to  institute  such  a  rule. 

Moreover,  such  medical  men  should  be  selected  for  trustees  as  by 
their  mental  training,  social  relations  and  personal  character  would  be, 
so  far  as  it  is  possible  for  human  nature  to  realize  such  a  position,  abso- 
lutely free  from  influences  arising  from  personal  jealousy  or  professional 
bias.  If  it  were  a  social  club,  it  would  be  perfectly  proper  to  vote 
against  a  man  because  he  is  personally  distasteful,  but  where  it  is  a 
scientific  body  responsible  for  the  education  of  large  numbers  of  young 
men  and  for  the  care  of  still  larger  numbers  of  hospital  patients  among 
the  poor,  even  if  a  candidate  were  personally  unfriendly  I  should  vote 
for  his  election  if  he  were  the  man  best  fitted  for  the  place. 

Turning  now  to  the  duties  and  responsibilities  peculiar  to  trustees 
of  hospitals,  let  me  point  out  the  objects  of  a  hospital :  First,  the  care 
and  cure  of  the  sick  and  injured;  secondly,  the  education  of  medical 
men  and  medical  students;  and,  thirdly,  the  promotion  of  knowledge, 
which,  in  turn,  will  inure  all  over  the  world  to  the  more  speedy  and 
certain  cure  of  the  sick  and  injured,  and  so  be- of  the  greatest  benefit  to 
humanity. 

In  order  to  accomplish  these  three  purposes,  it  is  necessary  that  the 
hospital  shall  have  sufficient  funds  to  purchase  ground,  erect  buildings 
and  provide  a  thorough  material  equipment.  It  is  a  great  pleasure  to 
me,  as  to  you  also,  to  note  that  throughout  the  length  and  breadth  of 
the  land  the  medical  and  surgical  staff  never  tax  the  always  inadequate 
resources  of  hospitals  for  any  remuneration.  They  serve  without  pay, 
they  give  their  time  and  skill  ungrudgingly  and  freely,  day  and  night, 
to  the  poor,  often  for  many  years,  without  ever  a  thought  of  any  money 
reward.  Their  reward  comes  from  increased  knowledge  and  skill,  and 
the  daily  blessing  invoked  of  heaven,  often  lisped  in  children's  prayers  or 
breathed  in  mothers'  benisons  which  pass  not  unheeded  by  the  Eecord- 
ing  Angel. 

But,  as  I  have  pointed  out  elsewhere,  instead  of  receiving  any  pay, 
they  give  to  hospitals.  The  mere  money  value  of  this  daily  gift  of  the 
profession  to  the  poor  amounts  to  an  enormous  sum.  The  value  of  the 
professional   services   of  the   staff   of   the   Jefferson   Medical    College 


PUBLIC   MEDICAL   INSTITUTIONS  465 

Hospital,  a  single  hospital  in  a  single  city,  on  a  moderate  basis  of  fees, 
I  found  was  more  than  half  a  million  dollars  annually.  The  millions 
upon  millions  of  money  given  in  that  most  self-sacrificing  form — 
personal  service — by  the  entire  profession  all  over  the  United  States, 
and  I  might  add  with  still  further  pride,  all  over  the  world,  is  simply 
incalculable.  The  Gideon  Grays  and  Weellum  MacLures  are  not  found 
only  in  Scotland  or  at  the  countryside.  They  are  even  more  plentiful 
in  the  slums  of  our  great  cities,  giving  of  their  time,  their  skill,  and — 
what  is  more — their  hearts,  their  lives,  themselves,  to  the  service  of 
humanity. 

Trustees  sometimes  seem  to  take  it  for  granted  that  their  duties  are 
ended  when  they  have  done  two  things :  begged  or  given  and  safely 
invested  the  necessary  funds,  and  then  elected  the  stafE.  To  my  mind, 
their  duties  do  not  by  any  means  end  at  this  point.  They  should  see  to 
it  that  the  resources  of  the  hospital  are  utilized  to  the  utmost  in  doing 
the  largest  good. 

Let  us  see  now  how  the  objects  of  a  hospital,  as  I  have  stated  them, 
can  be  realized.  The  first  object  is  the  care  and  cure  of  the  patients. 
But  the  cure  of  any  individual  patient  is  not  the  "be  all  and  the  end 
all"  of  a  hospital.  His  cure  must  be  a  means  of  larger  vision  to  the 
doctor,  who  will  thus  be  better  fitted  to  care  for  future  similar  cases. 
Even  the  death  of  the  patient,  if  he  can  not  be  cured,  should  minister 
to  the  increasing  knowledge  and  skill  of  the  doctor  so  that  he  may  be 
able  to  snatch  future  victory  from  present  defeat. 

The  second — the  training  of  doctors  and  students — is  frequently 
carried  out,  but  sometimes  even  objected  to.  There  are  three  classes  of 
doctors  who  are  trained  by  a  hospital:  First,  the  stafE  of  the  hospital 
itself.  I  have  lived  through  the  period  of  the  establishment  of  hospitals 
in  many  of  the  smaller  cities  and  towns,  and  in  some  cases  even  villages 
in  this  country,  for  it  was  a  rare  thing  in  my  early  professional  life  for 
any  except  the  larger  cities  to  have  hospitals.  The  moment  that  a 
hospital  is  established  with  its  medical  and  surgical  staff,  that  moment 
a  new  era  has  dawned  on  the  community  in  which  the  hospital  is  estab- 
lished. More  careful  methods  are  introduced,  greater  cleanliness  is 
observed,  hygienic  conditions  are  bettered,  laboratory  methods  are  in- 
evitably introduced  in  time.  Even  if  the  old-timers,  who  graduated 
years  before  our  modern  laboratory  methods  were  adopted,  do  not  care 
for  them  or  can  not  use  them,  the  young  fellows  who  come  fresh  from 

31 


466  MEDICAL    BESEABCE    AND    EDUCATION 

our  medical  schools  and  serve  as  residents,  and  even  the  nurses  graduated 
from  our  training  schools,  finally  shame  the  older  ones  into  better  ways 
and  greater  exactness,  not  only  in  the  hospital,  but  in  their  private 
work  as  well. 

As  a  consequence  of  the  establishment  of  these  hospitals  and  of  the 
added  skill  and  training  of  the  local  physicians  and  surgeons,  the  char- 
acter of  the  consultations  of  the  physicians  and  surgeons  of  our  great 
medical  centers  has  been  greatly  modified.  The  really  simple  cases, 
such  as  hydrocele  and  small  tumors  (and  even  some  large  ones),  club- 
foot, harelip,  etc.,  which  used  to  be  sent  to  city  consultants,  are  now  suc- 
cessfully operated  on  by  the  local  surgeons,  and  only  the  more  difficult, 
serious  or  complicated  cases  are  senj;  to  the  cities.  This  is  a  great 
advantage  to  the  patient,  whose  good  is  the  first  consideration,  and  to 
the  local  medical  men;  and,  though  seemingly  a  serious  loss  to  the  city 
consultant,  it  is  in  the  end  an  advantage,  as  he  must  prove  his  better 
mettle  in  the  higher  scientific  fields  and  be,  as  well  as  seem  to  be,  a 
better  man." 

Moreover,  the  trustees  of  every  hospital  should  see  to  it  that  a  good 
library  and  laboratory  are  provided.  Insensibly  the  staff  will  read 
more  and  more.  A  single  restless  progressive  spirit,  even  though  it  be  a 
young  interne,  calling  attention  to  this  case  and  to  that,  in  one  journal 
or  another,  will  compel  the  rest  of  the  stafE  to  read  in  spite  of  them- 
selves. It  is  absolutely  clear  that  a  laboratory  with  modern  equipment 
for  bacteriological,  pathological  and  chemical  research  in  its  examina- 
tion of  tumors,  the  urine,  the  sputum,  the  feces,  the  blood,  the  pus,  and 
other  fluids  from  wounds,  etc.,  is  a  necessity  in  every  hospital.  Even 
many  of  our  smaller  hospitals  are  equipped  with  microscope  and  re- 
agents, if  not  with  a  complete  bacteriological  outfit,  which  nowadays  is 
inexpensive  and  imperative.  All  of  this  raises  the  intellectual  and 
professional  standard  of  the  staff.  I  venture  to  say  that  no  town  of 
20,000  people  can  afford  to  be  without  its  hospital  for  the  sake  of  its 
oivn  citizens,  utterly  irrespective  of  the  good  it  does  to  the  poor  who  are 
treated  in  its  wards.  It  must  be  established  in  the  interest  of  the 
well-to-do  citizens  and  their  families,  so  that  they  may  secure  better 
equipped  doctors  for  themselves  as  well  as  for  the  patients  in  their 

'  [On  the  other  hand,  I  must  utter  a  warning.  The  doctor  who  does  a 
surgical  operation  only  occasionally  has  no  moral  or  surgical  right  to  attempt 
serious  operations  which  often  put  to  the  test  all  the  resources  of  a  veteran 
operator.] 


PUBLIC   MEDICAL   INSTITUTIONS  467 

hospital.  Self-interest,  therefore,  should  compel  every  community  to 
establish  its  hospital,  even  if  charitable  motives  had  no  influence. 

Again,  the  trustees  of  all  hospitals  of  any  size  should  establish  a 
training-school  for  nurses.  Only  those  who,  like  myself,  have  lived  in 
the  period  before  such  training  schools  were  established  can  appreciate 
the  vast  improvement  effected  in  a  hospital  by  this  change.  To  replace 
the  former  ignorant,  untrained  attendants  by  "trained  nurses  whose 
jaunty  caps  and  pretty  uniforms  and  often  winsome  faces  almost  make 
one  half  wish  to  be  sick,  and  when  one  is  sick,  half  loth  to  be  well," 
is  not  only  a  boon  to  the  patients,  but  to  the  doctors  as  well.  The  in- 
telligent, well-trained  nurse,  who  is  on  the  alert  to  observe  every  im- 
portant change  of  symptoms  and  who  will  keep  accurate  bedside  notes, 
is  the  doctor's  right  hand.  Xot  a  few  patients  who  would  otherwise 
lose  heart  and  hope  are,  one  may  say,  lured  back  to  health  and  happiness 
by  the  tactful  attentions  and  restful,  but  efficient  care  of  such  a  nurse. 
The  community  of  the  well-to-do  also  are  benefited,  because  the  hospital 
provides  them  with  skilled  nurses  in  their  homes  when  they  are  so  un- 
fortunate as  to  be  compelled  to  remain  there  instead  of  going  to  the 
hospital. 

The  old  repugnance  to  entering  a  hospital  when  sick  or  when  an 
operation  is  demanded  is  rapidly  fading  away.  The  immense  advan- 
tages of  a  good  hospital  over  the  most  luxurious  home  are  now  acknowl- 
edged  on  all  hands.  The  poorest  patient  in  a  hospital  is  better  cared 
for,  his  case  more  carefully  investigated  by  bacteriological,  chemical 
and  clinical  methods  in  a  hospital,  than  are  the  well-to-do  in  their  own 
homes.  Indeed,  wise  surgeons,  except  in  cases  of  emergency,  now  very 
properly  refuse  to  do  operations  in  homes  instead  of  in  hospitals.  In 
many  instances  lives  that  would  be  lost  in  homes  are  saved  in  hospitals, 
where  the  many  and  complex  modern  appliances  for  evei-y  surgical 
emergency  are  provided. 

The  hospitals  in  direct  or  indirect  connection  with  medical  schools, 
however,  do  a  far  larger  work  than  merely  the  training  of  their  own  staffs 
of  doctors.  They  train  three  other  classes  of  doctors :  First,  the  under- 
graduates who  are  aspiring  to  the  degree ;  second!}',  graduate  physician? 
who  spend  a  certain  amount  of  time  in  the  hospitals  either  as  internes  or 
as  temporary  students  refurbishing  their  professional  knowledge;  and 
thirdly,  experts  in  certain  branches  of  medicine  and  surgery. 

The  undergraduates  are  taught  first  in  the  general  clinics,  where 


468  MEDICAL   SESEAECH   AND   EDUCATION 

to  some  extent  they  learn  both  by  didactic  instruction  and  by  seeing  the 
patients,  hearing  their  histories,  and  witnessing  the  institution  of  proper 
treatment  by  prescription,  by  regimen,  or,  if  necessary,  by  surgical  opera- 
tion. This  is  of  great  value,  particularly  in  the  more  important  cases, 
and  especially,  for  I  speak  now  as  a  surgeon,  in  important  operations. 
It  is  often  objected  that  students  see  nothing  in  large  clinics.  To  some 
extent  this  holds  good ;  but  no  student  can  look  on  at  an  operation  when 
the  jugular  vein  or  the  lateral  sinus  is  torn,  the  pleural  cavity  opened, 
the  bowel  lacerated,  or  other  of  the  great  emergencies  of  surgery  occur, 
and  fail  to  be  impressed  by  the  coolness  of  the  operator,  the  carefully 
explained  methods  adopted  for  remedying  the  mischief,  and  the  various 
devices  used  to  save  life,  all  of  which  hereafter  will  be  used  by  himself 
when  similar  emergencies  may  occur. 

Yet  far  more  important  than  the  public  clinics  are  the  smaller 
clinics  held  with  classes  of  ten  to  twenty  men  each,  when  under  an 
experienced  teacher  the  absolute  work  of  the  clinic  is  divided  among  the 
various  students  in  turn,  watching  the  pulse  and  the  respiration,  giving 
an  anesthetic,  assisting  actively  at  operations,  percussing  the  chest, 
palpating  the  abdomen,  determining  inequalities  of  the  surface  or  the 
varying  density  of  underlying  organs.  Here  is  the  real  forum  in  which 
our  modern  medical  student  acquires  his  skill.^  In  many  cases  visits 
in  the  ward  itself  are  made,  and  to  a  small  group  around  the  bedside 
the  physician  or  surgeon  will  point  out  the  phenomena  to  be  recorded, 
the  need  for  the  examination  of  the  blood,  the  results  of  bacteriological 
cultures,  the  facts  discovered  by  the  microscope,  or  the  chemical  reagent. 
By  the  Socratic  method,  also,  he  will  reveal  to  the  student  the  imper- 
fection of  his  knowledge,  call  out — e-ducate — his  powers  of  observation, 
of  reasoning ;  stimulate  his  thought,  and  give  him  an  impetus  which  will 
last  throughout  life.  Who  that  has  "walked  the  hospitals"  with  a 
Skoda,  a  Trousseau,  a  Nelaton,  a  Da  Costa,  or  a  Mitchell  can  ever  forget 
their  teaching? 

It  is  sometimes  objected  by  those  who  are  not  familiar  with  the 
actual  facts,  and  especially  by  trustees,  that  this  method  of  actual  bed- 
side instruction  does  harm  to  the  sick.  I  speak  after  an  experience  of 
nearly  forty  years  as  a  surgeon  to  a  half  dozen  hospitals  and  can 
confidently  say  that  I  have  never  known  a  single  patient  injured  or  his 
chances  of  recovery  lessened  by  such  teaching.  Of  course,  the  surgeon 
or  physician  uses  common  sense.     He  would  not  allow  a  number  of 


PUBLIC   MEDICAL   INSTITUTIONS  469 

men  to  palpate  the  abdomen  of  a  patient  with  peritonitis,  or  move  an 
acutely  inflamed  Joint,  nor  would  the  ph3^sician  allow  a  patient  with 
pneumonia  to  have  the  chest  unduly  exposed,  or  a  typhoid  fever  patient 
disturbed  if  his  condition  were  such  that  it  would  be  inadvisable.  But 
such  cases  are  the  exception.  In  fact,  many  of  you  are  familiar  with 
patients  who  have  responded  to  repeated  percussion  by  members  of  such 
a  class  by  prompt  recovery,  attributed  by  the  patient  to  the  supposed 
medication  of  percussion.  Moreover,  it  is  by  this  actual  practise  only 
that  the  student  acquires  the  necessary  skill  in  the  use  of  modern 
instruments  of  precision,  such  as  the  stethoscope,  the  laryngoscope,  the 
esthesiometer,  the  sphygmomanometer,  the  various  specula.  Here  he 
learns  when  to  make  blood-counts,  how  to  take  histories,  arrive  at  the 
actual  facts  by  skillful  cross-questioning,  note  the  varying  s3Tnptoms  and 
physical  signs  of  a  case,  determine  the  need  for  laboratory  investigations, 
all  under  the  guidance  of  skilled  observers,  who  will  point  out  his  errors, 
encourage  his  queries,  and  stimulate  his  thought. 

Moreover,  trustees  may  overlook  one  important  advantage  of  a 
teaching  hospital.  Who  will  be  least  slovenly  and  careless  in  his  duties : 
he  who  prescribes  in  the  solitude  of  the  sick  chamber,  and  operates  with 
two  or  three  assistants  only,  or  he  whose  every  movement  is  eagerly 
watched  by  hundreds  of  eyes,  alert  to  detect  every  false  step,  the  omis- 
sion of  an  important  clinical  laboratory  investigation,  the  neglect  of 
the  careful  examination  of  the  back  as  well  as  the  front  of  the  chest, 
the  failure  to  detect  any  important  physical  sign  or  symptom?  Who 
will  be  most  certain  to  keep  up  with  the  progress  of  medical  science :  he 
who  works  alone  with  no  one  to  discover  his  ignorance,  or  he  who  is 
surrounded  by  a  lot  of  bright  young  fellows  who  have  read  the  last 
Lancet  or  the  newest  Annals  of  Surgery  and  can  trip  him  up  if  he  is  not 
abreast  of  the  times?  I  always  feel  at  the  Jefferson  Hospital  as  if  I 
were  on  the  run  with  a  pack  of  lively  dogs  at  my  heels.  I  can  not  afford 
to  have  the  youngsters  familiar  with  operations,  means  of  investigation, 
or  newer  methods  of  treatment  of  which  I  am  ignorant.  I  must  per- 
force study,  read,  catalogue,  and  remember,  or  give  place  to  others  who 
will.     Students  are  the  best  whip  and  spur  I  know. 

Of  the  value  of  training  graduates  in  post-graduate  work  I  need 
scarcely  speak, — to  this  audience  at  least.  The  doctor  who  graduated 
five,  ten,  or  fifteen  years  ago  comes  to  our  great  centers  of  medical 
education  and  renews  his  youth  at  the  fountain  of  knowledge.     He 


470  MEDICAL   BESEAECE   AND    EDUCATION 

learns  the  use  of  all  the  new  instruments,  see  new  methods  of  operation, 
new  methods  of  treatment,  new  means  of  diagnosis,  and  goes  home  an 
enormously  better  equipped  man. 

The  trustees  should  see  that  the  staff  does  not  become  fossilized  by 
following  the  same  ancient  local  methods  from  year  to  year,  but  should 
encourage  them  to  visit  other  hospitals,  see  other  men  operate,  hear 
other  men  discourse  on  the  latest  methods  of  investigation,  and  then 
import  into  their  own  hospitals  all  the  good  found  elsewhere.  I  learn 
a  deal  by  such  frequent  visits  to  the  clinics  of  my  brother-surgeons,  and 
if  one  wlio  has  grown  gray  in  the  service  can  thus  learn,  surely  the 
younger  men  can  do  so.  When  we  are  too  old  to  learn,  we  are  too  old 
to  remain  on  a  hospital  staff. 

I  do  not  know  anything  which  has  more  impressed  upon  me  the 
enormously  rapid  progress  which  surgery  is  making  than  a  recent  experi- 
ence. I  was  absent  from  this  country  for  almost  a  year  and  a  half.  In 
that  time  circumstances  were  such  that  I  saw  almost  no  medical  journals 
and  but  few  doctors.  I  have  been  home  now  eight  months  and  even 
with  incessant  work  I  have  not  yet  caught  up,  so  rapid  has  been  the 
progress  of  surgery  in  this  short  time.  Had  I  been  absent  for  five  years, 
verily  I  should  have  been  a  "  back  number,"  and  never  could  have  caught 
up  at  all. 

In  his  very  excellent  presidential  address  before  the  Association  of 
American  Physicians  in  1901,  Professor  Welch  made  a  plea  for  hospitals 
to  afford  "the  requisite  opportunities  to  young  men  who  aim  at  the 
higher  careers  in  clinical  medicine  and  surgery."  He  called  attention  to 
the  fact  that  in  our  bacteriological,  pathological  and  anatomical  labora- 
tories the  opportunities,  though  still  too  few,  were  reasonably  good,  and 
in  a  few  places  exceptionally  good,  for  the  training  of  young  men  for 
positions  as  teachers  of  anatomy,  pathology  and  bacteriology.  Any 
young  man  in  these  departments  who  by  good  hard  work  makes  for  him- 
self a  name  is  fairly  sure,  before  long,  of  being  called  to  some  important 
post  as  a  professor,  director  of  a  laboratory,  or  some  similar  position. 
But  the  facilities  for  work  in  clinical  medicine  and  clinical  surgery  are 
far  more  restricted,  since  opportunities  for  both  the  exercise  of  their 
clinical  skill  are  less  frequently  open  to  them  and  the  possibility  of  com- 
bined physiological,  pathological,  bacteriological  and  anatomical  re- 
search along  with  their  clinical  work  are  but  scantily  provided  for. 
This  plea  is  reinforced  by  a  recent  paper  of  Sir  Michael  Foster.^  These 
'^  Nineteenth  Century,  January,  1901,  p.  57. 


PUBLIC   MEDICAL   INSTITUTIONS  471 

special  graduates,  bright  young  men,  determined  to  devote  themselves 
to  one  or  another  department  of  medicine  or  surgery,  are  the  men  who 
bring  honor  to  the  school  at  which  they  obtain  their  training,  and  are 
invaluable  to  the  community.  They  are  future  Jenners,  Pasteurs, 
Virchows,  Listers,  Da  Costas  and  Grosses,  and  our  hospitals  should 
provide  exceptional  facilities  for  these  exceptional  men. 

The  third  object  of  a  hospital  is  the  promotion  of  knowledge,  and 
so,  fourthly,  the  good  of  humanity.  Physicians  and  surgeons  engaged 
only  in  private  practice  do  not  generally  keep  notes  of  their  cases,  and 
rarely  publish  important  contributions  to  knowledge.  I  find  in  100 
books  taken  consecutively  in  my  library  that  85  were  written  by  hospital 
men  and  only  15  by  authors  not  connected  with  any  hospital  so  far  as 
was  indicated  on  the  title  page. 

In  order  that  proper  investigations  may  go  on,  trustees  should  en- 
force a  permanent  record  of  all  the  cases  treated  in  the  hospital,  properly 
indexed,  from  which  the  staff  may  derive  their  data  for  papers  and  books. 
Each  large  hospital  should  have  its  pathological  resident  as  well  as  the 
clinical  residents  in  the  various  wards,  so  that  post-mortem  records  shall 
be  well  kept,  pathological,  bacteriological  and  chemical  investigations  of 
various  secretions  or  blood-counts,  etc.,  shall  be  properly  made  and 
permanently  recorded  in  such  a  manner — best  by  a  modern  card-cata- 
logue— as  to  be  accessible. 

It  is  too  often  the  case  that  trustees,  as  I  have  said,  regard  their 
duties  and  responsibilities  at  an  end  when  they  have  taken  care  of  the 
funds  and  elected  the  staff.  They  may  say  that,  after  all,  this  is  their 
real  duty,  and  that  all  I  have  advocated  is  medical  and  surgical,  and 
that  the  responsibility  for  it  should  devolve  on  the  staff,  and  not  on  the 
trustees.  I  do  not  take  so  narrow  a  view  of  the  duties  of  trustees. 
When  they  have  elected  a  physician  or  surgeon,  if  he  neglects  his  duty, 
it  is  their  business  to  displace  him  and  fill  his  place  with  another  man 
who  will  attend  to  his  duty,  and  the  duties  that  I  have  indicated  per- 
taining to  the  increase  of  knowledge  as  well  as  of  its  diffusion  are  quite 
as  much  within  their  province  as  it  is  to  see  that  the  funds  are  invested 
and  re-invested  to  the  best  advantage.  The  intellectual  funds  as  well  as 
the  invested  funds  must  bring  in  good  dividends. 

If  trustees  and  staff  work  together  for  such  a  purpose  and  in  such  a 
manner,  they  will  create  an  ideal  hospital  which  will  do  more  good  to 
the  patients  than  any  other  type  of  hospital.     It  will  attract  tlie  best 


472  MEDICAL   BESEABCH   AND   EDUCATION 

physicians  and  surgeons  in  every  community,  will  acquire  the  best 
reputation,  not  only  local,  but  it  well  may  be  national,  and  do  the  most 
for  the  good  of  science  and  the  benefit  of  humanity. 

It  may  be  said  that  this  is  an  unduly  strenuous  view  of  the  duties  of 
trustees,  that  in  our  father's  day  and  in  our  own  earlier  lives  no  such 
conditions  existed  or  were  contemplated.  Said  President  Eoosevelt  in 
addressing  the  Methodists  assembled  in  council : 

I  need  hardly  ask  a  body  like  this  to  remember  that  the  greatness  of  the 
fathers  becomes  to  the  children  a  shameful  thing  if  they  use  it  only  as  an  excuse 
for  inaction  instead  of  as  a  spur  to  effort  for  noble  aims.  .  .  .  The  instruments 
with  which,  and  the  surroundings  in  which  we  work  have  changed  immeasurably 
from  what  they  were  in  the  days  when  the  rough  backwood  preachers  minis- 
tered to  the  moral  and  spiritual  needs  of  the  rough  backwoods  congregations. 
But.  if  we  are  to  succeed,  the  spirit  in  which  we  do  our  work  must  be  the  same 
as  the  spirit  in  which  they  did  theirs. 

Moreover,  we  must  remember  that 

the  world  field  into  which  all  nations  are  coming  in  free  competition  by  the 
historical  movement  to  which  all  narrower  policies  must  sooner  or  later  yield, 
will  be  commanded  by  those  races  which,  in  addition  to  native  energy  and 
sagacity,  bring  the  resources  of  scientific  investigation  and  of  thorough 
education. 

The  international  race  for  the  leadership  of  the  world  is  just  as  strenu- 
ous and  intense  in  medicine  as  it  is  in  commerce.  If  we  are  going  to 
join  the  race  and  win  the  prize,  there  must  be  the  highest  development 
of  American  education  at  the  top.  The  best  men  must  be  pushed  to 
the  front,  and  ample  opportunities  for  growth,  for  investigation,  and  for 
original  research  must  be  provided.  Never  has  there  been  so  large  an 
opportunity  for  the  man  of  large  ideas,  complete  education,  and  in- 
domitable energy  and  purpose  as  there  is  to-day.  The  world  is  waiting, 
looking,  longing  for  him  and  will  cry  "  Make  room  "  for  him  when  he  is 
found. 

In  the  hands  of  the  trustees  of  our  colleges  and  hospitals  are  the 
money  and  the  opportunity  for  developing  such  men.  If  the  right 
spirit  pervades  both  trustees  and  medical  faculties  and  hospital  staffs, 
then  it  will  be  but  a  short  time  before  America  will  lead  the  world  in 
medicine  as  well  as  she  now  does  in  commerce. 

Will  the  profession  rise  to  the  level  of  their  great  opportunity? 
Yea,  verily  they  will !  Never  yet  have  they  been  wanting  when  the 
emergency  arose;  not  only  the  emergency  of  labor,  but  also  the  emer- 
gency of  danger. 


PUBLIC   MEDICAL   INSTITUTIONS  473 

In  Kussia  the  common  soldier  counts  for  little.  Yet  in  Vladikavkaz 
(where  the  Dariel  Pass — the  old  Porta  Caspiae  of  Herodotus — leading 
from  the  Caucasus  joins  the  railroad  from  Baku  on  the  Caspian  to 
Moscow)  is  a  monument  to  a  common  soldier.  At  the  last  battle  in 
which  the  Russians  won  the  victory  over  Schamyl  which  gave  them  un- 
disputed sway  over  the  Caucasus,  this  soldier  blew  up  a  mine  and  won 
the  day  at  the  cost  of  his  own  life.  It  was  ordered  that  his  name  should 
never  be  erased  from  the  list  of  his  company.  At  every  roll-call  when 
his  name  is  reached,  the  solemn  answer  is  given,  "  Died  in  the  service  of 
his  country." 

In  our  hospitals  lurk  the  deadly  breath  of  diphtheria,  the  fatal  virus 
of  bubonic  plague,  of  cholera,  of  5'ellow  fever,  of  typhoid  fever,  and  the 
ever-present  danger  of  blood-poisoning.  I  have  known  of  brother- 
physicians  who  have  died  victims  to  each  one  of  these  scourges.  Yet 
who  has  ever  known  one  of  our  guild  to  shrink  when  danger  smote  him 
on  the  right  hand  and  the  left  and  death  barred  the  way  ?  As  brave  as 
the  Russian  soldier,  ready  to  risk  life,  and,  if  need  be,  to  lose  it,  these 
martyrs  to  duty  shall  never  have  their  names  stricken  off  the  honor  list, 
and  at  the  last  roll-call  the  solemn  reply  shall  be,  "  Died  in  the  service 
of  humanity." 


EESEARCH   FOUNDATIONS   IN  THEIR   RELATION  TO 

MEDICINE^ 

By  Henry  H.  DoNALDSoisr,  Ph.D.,  Sc.D., 
The  Wistar  Institute  of  Anatomy 

At  this  time  and  place,  medicine  is  the  central  interest,  and  there- 
fore, so  far  as  a  layman  can,  it  is  my  purpose  to  discuss  "Research 
Foundations  in  their  Relation  to  Medicine,"  and  if  possible  to  do  this  in 
such  a  manner  as  to  reveal  their  significance  to  those  for  whose  en- 
couragement these  ceremonies  have  been  devised. 

To  accomplish  this  I  intend  first  to  ask  you  to  consider  the  mental 
attitude  necessary  for  the  appreciation  of  research  foundations  and  then 
to  describe  these  foundations  broadly — trying  to  indicate  their  relations 
to  the  universities;  the  problems  which  arise  in  connection  with  them; 
the  dangers  to  which  they  are  exposed;  and  their  significance  for  the 
progress  of  medicine,  for  yourselves  and  for  the  development  of  the 
spirit  of  research. 

You  who  are  about  to  pass  from  the  discipline  of  the  school  to  a 
more  self-dependent  phase  of  your  career  feel  both  the  fresh  pleasure  of 
restraints  outgrown  and  a  questing  interest  in  the  coming  years.  You 
feel  too  that,  broadly  speaking,  what  will  happen  to  medicine  during 
the  next  fifty  years  will  also  happen  to  you,  and  that  at  any  moment 
some  of  you  may  be  called  upon  to  guide  these  happenings. 

In  the  face  of  such  responsibilities  it  becomes  a  duty  as  well  as  a  wise 
precaution,  to  obtain  the  broadest  possible  view  across  your  chosen  field 
and  to  gain  knowledge  of  the  larger  changes  and  improvements  taking 
place  within  it. 

You  may  have  done  this  several  times  before,  but  I  venture  to  pre- 
dict that  if  you  live  and  succeed,  you  will  do  it  many  times  again. 

The  Greek  philosopher  Heraclitus  laid  weight  on  the  idea  that  all 
things  are  in  a  state  of  flux.  The  notion  has  not  always  been  approved. 
We  know  that  this  idea  in  some  of  its  aspects  was  repugnant  to  the 
early  Victorian  gentlemen,  but  to-day  we  are  less  prone  than  those  of 

'Address  at  the  graduation  exercises  of  the  Yale  Medical  School,  June  17, 
1912.     Published  in  Science,  July  19,  1912. 

474 


BESEABCH   FOUNDATIONS  475 

earlier  generations  to  dogmatize  on  the  impossible,  and  in  this  country 
and  this  phase  of  civilization  we  feel  with  its  full  force  the  forward 
flow  of  things,  so  that  for  us  nothing  is  more  certain  than  the  progressive 
change  and  onward  movement  in  medical  theory  and  hence  in  medical 
practise. 

During  the  years  of  your  training  you  have  been  carried  more  or 
less  unconsciously  along  and  thus  helped  to  keep  in  touch  with  the 
development  of  medical  thought,  but  at  this  moment,  when  the  stream 
of  knowledge  is  about  to  cast  you  out  upon  its  shores  and  you  are  asked 
to  walk  on  alone,  it  is  worth  while  to  inquire  what  is  your  preparation 
for  the  experience. 

From  these  halls  and  laboratories  you  bear  away  a  load  of  learning — 
haply  you  bear  it  lightly.  It  is  to  this  possession  that  I  wish  to  direct 
attention  for  a  moment. 

The  knowledge  we  accumulate  is  a  very  mixed  article,  but  in  this 
mixture  there  are  two  sorts  which  it  is  well  for  us  to  consider  now.  One 
sort  consists  of  certain  formulas  which  control  our  incidental  actions ; 
for  instance,  we  all  know  on, occasion  when  to  stand  up  or  to  sit  down, 
and  you  know  the  technique  and  procedure  for  various  surgical  opera- 
tions. A  great  fraction  of  our  information  is  in  this  form,  a  form  not 
necessarily  subject  to  frequent  or  radical  change.  This  sort,  however, 
is  of  minor  interest  to  us  now,  and  has  been  mentioned  here  only  that 
it  may  serve  as  a  foil  to  the  more  important  kind. 

This  more  important  kind  of  knowledge  is  that  on  the  basis  of  which 
we  can  foresee  and  predict. 

There  are  manifold  varieties  of  this  and  they  range  from  that  which 
permits  us  to  predict  with  a  high  degree  of  confidence  the  rising  of  to- 
morrow's sun,  to  that  with  which  one  ventures  to  predict  the  weather 
or  the  fate  of  a  patient  with  baffling  symptoms. 

In  these  latter  instances  the  cause  of  events  is  by  no  means  unpre- 
dictable, but  only  so  dependent  on  complex  factors  and  conditions  that 
we  rarely  have  at  once  at  hand  enough  information  to  make  a  respect- 
able guess.  This  fact  bears  very  directly  on  the  matter  before  us,  for 
when  we  scrutinize  our  intellectual  possessions  we  find  them  to  consist 
in  large  measure  of  information  useful  for  prediction,  yet  mainly  in- 
formation so  incomplete  that  the  conclusions  or  theories — if  you  choose 
— based  on  it  must  be  largely  held  as  open  to  revision  and  therefore 
can  be  used  with  safety  only  by  those  who  carry  in  mind  just  how  much 


476  MEDICAL  BESEABCH  AND  EDUCATION 

or  how  little  each  conclusion  has  to  rest  upon.  Kevertheless,  it  is  just 
these  tentative  conclusions  or  theories  which  the  medical  man  must  so 
largely  utilize.  Probably  you  have  thought  of  this  before;  if  so,  you 
know  that  to  the  revelations  of  this  analysis  men  react  in  very  different 
ways.  Some  throw  up  their  hands  in  the  face  of  so  much  uncertainty ; 
others  stretch  certainty  to  the  limit  and  seek  to  make  it  cover  all  they 
have  been  taught  and  then  cultivate  impenetrability  because  change  is 
disquieting  and  new  knowledge  means  new  labor,  while  those  born  under 
happier  stars  are  neither  crushed  nor  blinded,  but  recognize  that  intel- 
lectual health  and  vigor  imply  an  unceasing  replacement  of  both  data 
and  conclusions,  to  be  accomplished  only  when  the  period  of  mental 
growth  is  made  conterminous  with  life. 

Capacity  for  such  continued  growth  is  conspicuous  in  the  masters 
and  a  hall  mark  of  the  eminent.  Indeed,  as  you  proceed  in  the  in- 
vestigation of  your  fellows,  you  will  be  surprised  to  find  how  early 
growth  may  cease  and  how  significant  the  event  can  be.  In  far-distant 
communities  mental  growth  has  been  known  to  stop  on  commencement 
day.  It  is  consoling,  however,  to  be  assured — as  I  can  assure  you — that 
we  observe  this  woeful  arrest  more  clearly  and  sooner  in  our  fellows 
than  in  ourselves — a  suggestive  fact  which  needs  only  to  be  mentioned 
in  order  to  be  appreciated. 

As  you  see,  the  reason  for  this  preface  touching  the  nature  of  our 
mental  possessions  is  my  wish  to  emphasize  the  need  for  the  full  recogni- 
tion of  the  unsolved  or  partly  solved  problems  in  medicine  and  the 
necessity  for  holding  in  mind  the  facts  on  which  all  such  tentative  solu- 
tions as  we  use  are  based.  When  this  need  has  been  recognized,  it  is 
possible  to  take  the  point  of  view  from  which  research  foundations  can 
be  discussed  with  greatest  benefit,  for  primarily  it  is  their  purpose  to 
replace  less  certain  by  more  certain  facts.  Indeed,  discussion  of  these 
foundations  can  be  significant  only  for  those  who,  like  yourselves,  know 
that  the  students'  career  is  for  life,  never  to  be  commuted — not  even  for 
good  behavior — and  in  no  wise  limited  by  any  formal  function,  such  as 
graduation  or  a  state  board  test. 

Turning  now  to  the  research  foundations  themselves,  it  may  be  well, 
by  way  of  introduction,  to  give  a  word  of  explanation  touching  the 
coming  treatment  of  them.  I  desire  to  speak  as  an  inquirer,  not  as  an 
advocate,  but  as  these  inquiries  have  led  me  to  some  definite  conclusions, 
I  shall  venture  to  express  them  briefly.  Beyond  this,  all  things  rest 
with  you. 


EESEABCH    FOUNDATIONS  477 

While  we  are  specially  interested  in  research  foundations  in  their 
relation  to  medicine,  yet  those  with  such  relations  are  but  a  fraction  of 
the  number  in  existence  and  for  the  most  part  have  come  late. 

A  research  foundation  may  be  defined  as  one  especially  intended 
to  produce  new  and  better  knowledge.  Thus  the  main  purpose  and  aim 
serves  broadly  to  differentiate  such  a  foundation  from  the  universities 
and  other  educational  establishments  in  which  a  greater  emphasis  is  put 
on  the  conservation,  distribution  or  application  of  knowledge,  while  at 
the  same  time  both  sorts  of  institutions  have  been  and  are  producers 
also.  The  new  foundations  are  then  by  no  means  essentially  novel,  but 
in  one  sense  outgrowths  or  specialized  extensions  of  the  older  educational 
establishments.  This  implies,  of  course,  that  what  they  are  devised  to 
do  has  already  been  included  in  the  existing  scheme  of  things. 

Such  being  the  case,  our  discussion  must  be  framed  so  as  to  comprise 
these  facts. 

In  the  civilization  from  which  we  are  descended  there  has  always 
been  some  endeavor  to  add  to  the  sum  of  human  knowledge. 

The  acute  minds  belonging  to  the  end  of  the  medieval  period  often 
overstepped  the  theological  and  philosophical  bounds  within  which  they 
had  their  greatest  activity,  and  gave  to  the  study  of  the  physical  world 
more  or  less  attention.  Speculating,  compiling,  teaching  and  even 
experimenting,  these  men  grouped  here  and  there  formed  the  centers 
from  which  the  earliest  universities  of  our  era  sprang. 

Later  appeared  the  learned  academies,  also  sometimes  the  patrons  of 
investigation.  As  objects  of  study,  the  physical  problems  came  first, 
aided  by  the  fact  that  observational  and  experimental  work  could  be 
there  begun  without  the  preliminary  labors  of  collection  and  classifica- 
tion which  have  necessarily  occupied  so  much  time  in  the  biological 
sciences. 

What  is  important  to  point  out  here  is  this :  That  whether  we  date 
the  founding  of  the  modern  university  laboratory  from  LomonossoS  at 
St.  Petersburg  in  1748,  or  from  Liebig  at  Giessen  in  1836,  we  must 
admit  that  a  good  deal  of  investigation  had  gone  on  in  all  the  principal 
departments  of  science  previous  to  such  foundations,  and  thus  in  earlier 
times  investigations  were  made  in  scientific  workshops  unconnected 
with  teaching  institutions.  This  fact  suggests  that  perhaps  our  re- 
search foundations  have  even  less  novelty  than  we  were  at  first  inclined 
to  accord  to  them,  and  that  we  are  dealing  now  rather  with  a  reappear- 


478  MEDICAL  BESEABCH  AND  EDUCATION 

ance  of  conditions — much  improved,  to  be  sure — but  quite  familiar 
before  the  rise  of  our  modern  universities.  It  has  a  direct  bearing  on 
this  point  to  note  that  in  England,  for  example,  during  the  earlier  part 
of  the  last  century  when  the  historic  universities  of  that  country  gave 
only  meager  support  to  experimental  science  and  especially  to  the  bio- 
logical investigations,  much  of  the  most  important  work  was  done  out- 
side of  the  teaching  institutions. 

Joule,  the  student  of  the  mechanical  equivalent  of  heat;  Perkin, 
discoverer  of  the  aniline  dyes;  Bentham  and  the  Hookers,  all  three 
botanists ;  Galton,  the  anthropologist,  and  Darwin,  are  some  instances. 

Moreover,  for  more  than  a  century  the  Eoyal  Institution  of  Great 
Britain,  the  foundation  of  which  in  1799  was  largely  instigated  by  our 
fellow  countryman.  Count  Rumford,  furnished  opportunities  for  re- 
search to  Davy,  Faraday,  Tyndall  and  Dewar,  all  men  whose  contribu- 
tions to  knowledge  have  been  of  great  importance. 

According  to  its  charter,  the  Eoyal  Institution  was  "an  establish- 
ment in  London  for  diffusing  the  knowledge  of  useful  mechanical  im- 
provements "  and  "  to  teach  the  application  of  science  to  the  useful 
purposes  of  life." 

This  does  not  sound  like  the  program  of  a  research  institution  to- 
day. I  can  not  say  just  what  the  steps  were  wiiich  led  in  this  case  to 
a  development  seemingly  so  different  from  that  proposed,  but  it  is  not 
rash  to  assume  that  the  men  like  those  who  have  been  named  were 
always  hunting  reasons  and  explanations,  knowing  quite  well  that 
others  could  carry  out  the  application,  while  it  was  theirs  to  make  the 
fundamental  discoveries;  an  excellent  example  of  the  well-known  fact 
that  where  an  institution  and  a  strong  man  are  left  to  work  out  the 
problem  of  adaptation,  it  is  the  institution  that  gets  adapted. 

Returning  from  this  diversion  to  our  history,  and  taking  the  period 
from  the  middle  of  the  preceding  century  to  the  present  day,  one  can 
not  fail  to  recall  in  this  country  such  an  example  as  the  Smithsonian 
Institution  at  Washington,  and  I  would  add  our  agricultural  experi- 
ment stations  which  started  right,  then  faltered,  but  are  now  coming 
into  their  own. 

More  extensive  in  scope  and  with  far  greater  resources  than  any  of 
these  is  the  Carnegie  Institution  of  Washington,  whose  magnificent 
undertakings  in  the  field  of  science  are  well  known,  representing  as 
they  do  a  long  series  of  research  stations. 


BE  SEARCH   FOUNDATIONS  479 

The  ideas  behind  these  several  foundations  are  of  the  greatest  in- 
terest. In  his  program  of  organization,  in  1847  Joseph  Henry,  first 
secretary  of  the  Smithsonian  Institution,  states  the  following : 

To  increase  knowledge:  it  is  proposed  (1)  to  stimulate  men  of  talent  to 
make  original  researches  by  offering  suitable  rewards  for  memoirs  containing 
new  truths  and  (2)  to  appropriate  annually  a  portion  of  the  income  for  par- 
ticular researches  under  the  direction  of  suitable  persons. 

This  is  what  one  might  expect  from  Joseph  Henry.- 
Touching  the  agricultural  experiment  stations,  the  history  is  com- 
plicated and  perplexing,  but  we  are  justified,  I  believe,  in  carrying  back 
the  guiding  idea  in  their  development  to  that  expressed  by  Washington 
in  his  annual  message  to  Congress  in  1796,  where  he  says,  when  pleading 
for  the  establishment  of  a  national  board  of  agriculture,  that  one  of  the 
functions  of  such  a  board  should  be  "  to  encourage  and  assist  a  spirit  of 
discovery  and  improvement  ...  by  stimulating  to  enterprise  and  experi- 
ment."    This  is  certainly  sound  doctrine. 

The  Carnegie  Institution  in  the  original  formulation  of  its  general 
plans  was  much  influenced  by  the  experience  and  early  program  of  the 
Smithsonian  Institution,  but  the  original  statement  of  aims  strikes  a 
new  note  when  it  declares  one  of  these  aims  to  be 

To  discover  the  exceptional  man  in  every  department  of  study  whenever 
and  wherever  found,  inside  or  outside  of  schools,  and  enable  him  by  financial  aid 
to  make  the  work  for  which  he  seems  specially  designed,  his  life  work. 

It  is  said  that  this  paragraph  touching  the  exceptional  man  has 
caused  much  trouble  to  the  Carnegie  Institution  and  often  spread  its 
path  with  thorns.  It  appears  that  in  some  instances  it  has  been  mis- 
understood. Self-discovered  exceptional  men  have  proved  to  be  em- 
barrassingly numerous.  That  does  not  strike  one  as  so  very  strange, 
however,  since  the  community  grows  wise  but  slowly. 

The  word  "exceptional"  you  see  has  suflEered  misinterpretation. 
The  really  exceptional  man  is  not  so  often  the  aberrant  prodig}''  as  the 
individual  who  presents  in  his  composition  a  large  collection  of  first- 
rate  qualities,  no  one  of  which  is  necessarily  alarming,  but  all  of  which 
together  make  for  scientific  effectiveness  of  the  highest  order.  In  the 
course  of  its  development,  the  Carnegie  Institution  has,  I  think,  lived 
up  to  this  ideal  with  notable  success — putting  the  saner  interpretation 
on  the  word  "exceptional."  My  commendation  of  the  paragraph  is 
similarly  based. 

But  none  of  these  instances  which  I  have  mentioned — together  with 


480  MEDICAL   EESEAECH  AND  EDUCATION 

a  large  group  of  others — come  very  close  to  medicine.  This  contact 
was  first  clearly  established  in  1888  by  the  Pasteur  Institute  in  Paris, 
an  institute  intended  to  facilitate  the  work  of  the  great  scientist  whose 
name  it  bore,  and  to  continue  the  remembrance  of  him.  It  was  an 
instance  of  the  generous  giving  of  aid  and  assistance  to  a  master-man — 
with  no  prescriptions  and  no  hampering  limitations.  Pasteur  was  a 
genius  who  combined  the  art  of  mediation  between  the  laboratory  facts 
and  practical  problems,  with  the  capacity  for  speculative  thought  and 
scientific  achievement  in  the  highest  sense,  and  who,  nevertheless,  did 
not  allow  his  human  interest  to  impair  his  scientific  thoroughness- 

In  this  country  among  the  foundations  closely  related  to  medicine 
we  have  recently  seen  established  the  Eockefeller  Institute,  the  Memorial 
Institute  for  Infectious  Diseases,  the  Ortho  S.  A.  Sprague  Memorial 
Institute,  both  of  these  at  Chicago,  together  with  a  number  of  others 
representing  much  the  same  purpose,  but  with  less  ample  resources,  as 
well  as  several  funds  devoted  to  the  study  of  cancer,  tuberculosis  or  other 
special  diseases.  These  instances,  because  they  touch  medicine,  might 
well  be  examined  in  detail,  but  we  shall  discuss  them  only  in  their  most 
general  relations. 

It  seems  a  fair  question  to  ask  why  these  institutes  and  funds  have 
been  established.  The  immediate  causes  are^plain  enough,  and  are 
frankly  philanthropic  in  most  cases.  Personal  experience  with  a  disease 
has  led  more  than  one  man  to  devote  a  large  sum  to  the  search  for  its 
control  or  cure,  or,  going  a  step  further  and  recognizing  that  the  ap- 
plication of  laboratory  results  to  medicine  has  brought  progress,  some 
have  desired  to  furnish  opportunities  by  which  this  application  may  be 
accomplished  where  it  seemed  most  needed.  Though  not  always  ex- 
plicitly expressed,  the  programs  of  these  foundations  imply  the  hope 
that  by  such  endowments  new  facts  and  new  points  of  view  funda- 
mentally important  to  medicine  may  be  discovered. 

I  like  to  think  that  this  last  idea  is  at  least  latent  in  all  these  en- 
deavors, but  nowhere,  so  far  as  I  know,  is  quite  the  same  note  struck  as 
that  which  is  sounded  in  the  initial  program  of  the  Carnegie  Institution 
in  those  words  which  call  attention  to  the  exceptional  man — the 
investigator. 

Turning  now  to  some  of  the  relations  involved,  it  is  to  be  observed 
that  these  new  foundations  are  independent  and  not  connected  with 
existing  universities,  that  they  tend  to  draw  men  from  university  posi- 


BESEABCE   FOUNDATIONS  481 

tions  by  the  attraction  of  unusual  opportunities  for  work,  and  finally, 
that  for  the  most  part  they  take  these  men  away  from  formal  teacliing. 

The  situation  thus  created  in  the  world  of  education  has  often  been 
lamented  and  no  little  moral  pressure  is  exerted  from  time  to  time 
to  induce  the  institutes  to  see  the  wrongness  of  their  position. 

The  question  thus  raised  amounts  to  this:  Are  these  new  founda- 
tions philanthropic  vagaries  and  mere  torsos  of  educational  establish- 
ments, or  do  they  represent  the  result  of  mature  consideration  and  a 
definite  endeavor  to  advance? 

Of  the  several  reasons  which  have  brought  about  the  independence 
of  these  foundations  the  common  desire  to  keep  alive  the  donor's  name 
and  fame  has  played  its  part,  but  more  than  this  I  think  has  been  the 
feeling  that  since  these  foundations  were  to  be  devoted  to  research, 
either  in  the  line  of  mediation  to  which  I  have  already  referred,  or  in 
the  endeavor  to  obtain  new  truths  of  fundamental  importance,  therefore 
the  workers  in  these  institutes  should  be  as  far  as  possible  released  from 
any  duties  likely  to  divert  their  energies.  To  make  this  arrangement 
within  the  limits  of  a  university  is,  to  say  the  least,  to  subject  the 
favored  appointee  to  no  little  strain. 

His  colleagues,  being  human,  at  heart  often  resent  his  seeming 
freedom  from  responsibility  and  he  is  allowed  to  feel  that  somehow  he 
does  not  justify  himself  by  attending  to  his  work  alone.  It  is  unneces- 
sary to  enlarge  on  this  situation,  but  I  can  assure  you  that  it  is  no  mere 
product  of  my  fancy.  Separateness  of  management  brings  protection 
therefore  to  those  who  choose  this  work. 

Still  more  important  for  ultimate  success  is  the  general  conduct  of 
such  a  foundation.  Our  universities  are  guided  by  experienced  admin- 
istrators who  feel  keenly  the  need  for  the  diffusion  of  knowledge,  for 
making  it  accessible  to  large  numbers  and  for  preserving  withal  a  com- 
pleteness and  balance  in  their  institutions. 

These  views  become  ingrained,  but  they  do  not  represent  the  aims 
of  a  research  foundation  and  the  same  board  could  hardly  manage  both 
with  like  success.  For  the  investigator,  buildings  are  fine  when  they 
suit  his  purpose;  after  that  he  loses  interest.  His  notion  of  efl&ciency 
is  a  large  emergency  fund,  and  whether  the  fixed  charges  are  great  or 
small  is  not  so  important  as  the  means  to  act  promptly,  decisively  and 
even  expensively  when  occasions  arise.  This  arrangement  is  possible 
only  when  the  institution  is  a  good  deal  of  a  unit  and  absolutely  free. 

32 


482  MEDICAL   BESEAECH  AND   EDUCATION 

To  appreciate  the  needs  thus  briefly  outlined  requires  the  experience 
which  breeds  sympathy,  and  it  has  thus  come  to  pass  that  so  far  as  the 
arrangement  of  the  scientific  program,  the  formation  of  the  personnel 
and  the  expenditure  of  funds  are  concerned,  the  control  in  many  of  our 
institutes  is  in  the  hands  of  the  staff,  aided  by  a  small  group  of  scientific 
advisers,  themselves  active  workers  and  keenly  alive  to  the  needs  of  the 
investigator.  This  leaves  the  actual  care  of  the  funds  with  the  trustees, 
but  puts  the  scientific  activities  in  the  hands  of  scientific  men.  The 
arrangement  solves  several  problems  and  seems  essential  for  the  healthy 
development  of  research  foundations. 

In  view  of  all  of  these  facts  it  does  not  appear  very  strange  that  inde- 
pendence has  been  desired  for  the  newer  establishments. 

This  brings  us  to  the  problem  of  getting  men — men  who  will  at- 
tempt to  realize  the  highest  aims  and  aspirations  of  these  foundations. 
These  have  been  taken  largely  from  university  laboratories  and  have 
been  attracted  to  the  newer  work  by  the  prospect  of  more  time  and 
resources  to  apply  to  their  chosen  problems  and  by  more  fitting  salaries. 

Of  course  it  has  happened  at  times  that  in  arranging  the  program 
of  some  foundations,  emphasis  has  been  put  on  finding  the  answer  to 
some  specific  question  which  was  in  the  donor's  mind.  This  is  unfor- 
tunate so  far  as  it  implies  a  limitation  of  the  scientific  work,  but  on  the 
other  hand,  in  many  cases  the  investigator  has  been  given  ample  freedom 
to  jDursue  his  own  courses  and  devote  his  time  to  matters  often  seemingly 
remote;  in  other  words,  to  follow  where  his  research  led.  The  situa- 
tion demands  above  all  things  faith  in  the  sincerity  of  purpose  of  the 
investigator,  and  fortunately  this  is  granted  with  increasing  frequency. 

In  these  institutions  which  serve  to  mediate,  on  the  one  hand, 
between  the  findings  of  science  and  practical  problems,  and  on  the  other 
to  give  opportunity  for  the  attainment  of  fundamental  facts,  there  is  a 
constant  danger  threatening  every  searcher  after  new  knowledge.  The 
mediation  work,  because  it  involves  as  one  element  a  practical  problem, 
is  moderately  intelligible  to  the  laity  and  extremely  handy  when  it 
comes  to  giving  an  account  of  things  done.  It  may  become  thereby 
undul}'  attractive. 

By  contrast,  the  search  for  the  new  knowledge  is  rarely  intelligible 
to  the  community  at  large,  and  must  often  be  described  in  terms  of 
things  in  mind  rather  than  of  things  accomplished,  and  thus  this  kind  of 
activity  often  lacks  for  encouragement.    Let  me  illustrate.    Some  years 


RESEABCH    FOUNDATIONS  483 

ago  the  need  of  protection  from  diphtheria  was  urgent.  The  infecting 
organism  and  its  biological  characters,  on  the  one  hand,  were  known; 
on  the  other,  the  dread  disease  was  only  too  familiar.  How  could 
laboratory  knowledge  be  used  to  solve  the  clinical  problem?  You  are 
familiar  with  the  answer  which  was  given  in  the  form  of  the  diphtheria 
antitoxin.  That  is  a  splendid  example  of  work  in  mediation  as  done  in 
research  institutes. 

But  a  further  question  arises:  How  does  the  antitoxin  produce  its 
effect  ?  This  is  quite  another  sort  of  problem ;  at  first  glance  it  appears 
to  have  little  practical  bearing  and  yet  the  answer  to  it  in  even  one 
instance  may  lead  to  a  wider  view  of  the  process  of  immunity.  The 
solution  of  problems  of  this  class  is  different  from  the  work  of  media- 
tion, certainly  of  equal  rank  with  it,  and  yet  in  every  way  harder  to 
support  and  harder  to  carry  on,  since  the  results  can  not  in  the  first 
instance  possibly  appeal  to  any  save  the  well-trained  few.  In  this  there 
lies  an  obstacle  to  progress  which  you  can  largely  help  to  remove. 

Because  the  men  who  can  do  this  latter  kind  of  work  are  relatively 
rare,  even  among  investigators,  because  such  work  can  have  rational 
appreciation  from  a  limited  group  only,  and  because  knowledge  of  this 
sort  is  sure  to  become  the  basis  for  many  mediations  in  the  future,  it 
behooves  us  all  to  see  to  it  that  we  foster  such  investigators — the  most 
valuable  of  our  natural  resources.  Perhaps  it  occurs  to  some  of  you  that 
you  have  seen  one  well-known  type  of  the  man  I  here  commend.  Let 
me  recall  him  to  you. 

An  elderly  gentleman  with  an  unprogressive  costume  and  unsteady 
gait,  who  generally  fails  to  recognize  his  friends  upon  the  street  and 
requires  several  seconds  to  accomplish  the  recall  when  spoken  to.  Such 
is  the  mildly  humorous  picture  with  which  all  are  familiar.  It  is  often 
correct  so  far  as  it  goes — only  it  is  a  bit  incomplete. 

One  should  add  that  this  man  is  working  with  his  head,  a  fact  which 
accounts  for  almost  everything  and  leaves  us  pondering  why  this  symp- 
tom complex  so  readily  excites  remark. 

Connected  with  the  conduct  of  research  in  these  foundations  are 
several  other  problems  of  more  than  passing  interest.  The  fear  is  some- 
times voiced  that  in  the  absence  of  students,  those  at  work  will  lack  an 
important  stimulus  and  suffer  deterioration. 

The  danger  varies  with  the  man.  Instances  are  known  where  men 
have  failed  to  feel  the  attraction  of  institute  opportunities,  because  they 
feared  the  loss  of  this  companionship. 


484  MEDICAL   BESEAECH  AND  EDUCATION 

On  the  other  hand,  we  have  the  attitude  represented  by  the  German 
■university  professor  who  is  said  to  have  remarked  at  the  opening  of  the 
fall  semester,  "  Now  comes  this  disagreeable  interruption  of  my  work." 
Doubtless  he  was  a  wicked  old  dyspeptic,  but  for  a  moment  he  rose 
beyond  himself  and  spoke  for  his  burden-bearing  caste. 

Let  me  beg  not  to  be  misunderstood.  I  would  not  for  a  moment  be 
thought  to  maintain  more  than  the  simple  thesis  that  while  teaching 
is  a  genuine  stimulant  to  some,  it  is  certainly  a  depressant  to  others 
and  especially  a  depressant  to  those  who  are  disturbed  by  interruption, 
so  that  some  can  drop  it  without  damage  to  themselves. 

In  compensation  it  may  be  urged  that  the  effect  of  the  investigator's 
methods  and  personality  is  felt  by  those  with  whom  he  is  usually  sur- 
rounded, his  colleagues  and  assistants,  and  when  so  surrounded  he  is  in 
no  more  danger  of  isolation  than  a  man  in  the  university.  However, 
that  is  not  saying  very  much,  for  isolation  among  colleagues  even  in 
universities  is  a  condition  which  we  not  only  lament,  but  should  also 
seek  to  change.     It  is  an  ancient  tale. 

The  investigators  of  four  centuries  ago  were  chary  of  talking  of 
their  results  and  these  were  often  published  posthumously,  as  the 
authors  preferred  to  die  without  assistance — or  the  new  discoveries 
were  sometimes  couched  in  cryptic  writings  as -though  the  author  felt 
that  what  had  given  him  such  years  of  labor  to  find  out  should  at  least 
he  hard  for  others  to  attain.    That  feeling  is  sometimes  found  to-day. 

Once  I  remarked  to  a  student,  "  Your  thesis  is  three  times  too  long." 
■*'  Yes,"  he  replied,  "  but  if  I  did  not  make  it  long,  how  would  any  one 
know  it  had  taken  me  two  years  to  do  the  work."  We  can  replace  this  by 
a  better  thought.  The  opportunity  to  satisfy  one's  longing  for  research 
is  a  noble  privilege,  but  it  brings  its  obligations.  The  advances  thus 
made  should  be  returned  as  rapidly  as  possible  to  the  fund  of  common 
knowledge,  and  made  accessible  to  the  community  at  large. 

This  is  essential  for  the  progress  of  the  plan,  for  most  surely  is  the 
advanced  worker  dependent  on  his  colleagues  as  they  on  him,  and 
ultimately  too  he  is  in  a  larger  sense  also  dependent  on  the  community 
about  him;  so  for  both  these  reasons  cooperation  of  the  most  complete 
sort  is  needful  for  the  common  good. 

Expression  has  been  given  to  the  fear  that  the  great  resources  of  our 
research  foundations  would  breed  despondency  among  those  who  were 
compelled  to  work  with  simpler  devices  and  less  ample  means,  and  thus 


SESEAECH    FOUNDATIONS  485 

they  would  do  harm.    Despondency  and  research  do  not  dwell  together. 

Eesearch  is  a  frame  of  mind.  A  man  may  have  little  leisure  and 
trifling  resources,  may  never  have  published,  but  if  he  examines  his 
world  in  a  questioning  spirit,  if  he  carries  with  him  not  only  conclu- 
sions, but  the  observations  on  which  they  rest,  if  he  refuses  to  pound 
square  facts  into  the  round  holes  that  he  happens  to  have  in  hand,  he 
has  attained  illumination.  The  spirit  of  research  is  nothing  mysterious 
or  remote,  it  is  every-day  hard  sense.  Unfortunately,  that  does  not 
make  it  common,  but  it  does  make  it  attainable. 

It  would  be  a  sorry  outcome  of  these  new  foundations  if  they  should 
act  as  hindrances  to  investigation  in  the  university  laboratories. 

The  fear  that  they  will  do  this  is  often  based  on  the  false  impression 
that  the  supply  of  scientific  problems  is  limited  and  thus  in  danger  of 
exhaustion.  Let  us  be  rid  of  that  idea.  Every  advance  creates  new 
problems,  problems  of  increasing  importance — exhaustion  is  impossible. 

By  reason  of  the  permanency  of  their  programs  and  freedom  from 
certain  forms  of  responsibility,  institutes  may  wisely  undertake  investi- 
gations of  a  sort  hardly  possible  under  university  conditions.  The  field 
is  thus  divided,  or  rather  enlarged.  Both  the  university  laboratories  and 
the  institutes  should  gain  by  this  arrangement,  and  what  is  more, 
they  do. 

Before  leaving  this  aspect  of  our  problem,  permit  me  to  point  out  a 
peculiar  advantage  enjoyed  by  investigators  who  are  working  under  uni- 
versity conditions.  "When  we  contrast  the  institutes  with  the  univer- 
sities, we  find  that  it  is  within  the  walls  of  the  university  laboratory 
that  it  is  most  easy  to  carry  on  the  search  for  new  knowledge  undis- 
turbed by  the  thought  of  any  applications  which  it  may  have. 

In  the  face  of  some  things  already  said,  this  statement  may  appear 
paradoxical — yet  it  describes  a  condition.  In  the  judgment  of  the 
educated  public,  the  teaching  investigator  fulfills  his  public  obligations 
when  he  gives  a  stated  amount  of  instruction.  After  that,  there  is  a 
general  feeling  that  the  man  should  be  allowed  to  follow  his  bent,  and 
if  this  takes  the  form  of  research,  the  community  does  not  feel  obliged 
to  enquire  too  closely  concerning  the  practical  value  of  the  work.  Thus 
in  a  way  the  university  man  is  protected  in  his  research  by  his  teaching 
obligations,  while  the  man  in  the  institute,  engaged  in  the  same  sort 
of  investigation,  is,  if  anything,  more  open  to  criticism,  and  at  the 
same  time  without  the  defense  which  is  possessed  by  his  university 
colleague,  and  in  so  far  he  stands  at  a  disadvantage. 


486  MEDICAL  BESEABCE  AND  EDUCATION 

As  you  see,  I  have  been  concerned  in  this  address  with  medicine  as 
represented  by  yourselves  in  relation  to  the  research  institutes,  and  that 
explains  the  manner  of  this  presentation. 

It  has  been  my  purpose  to  show  that  in  these  foundations  we  have 
something  which  represents  an  advance  in  our  educational  devices. 

Their  independence  is  an  asset.  They  may  be  counted  on  to  mediate 
in  a  measure  between  the  initial  facts  of  the  laboratory  and  the  problems 
presented  by  disease,  but  more  important,  though  harder  to  maintain, 
is  their  function  as  laboratories  where  new  knowledge  is  obtained,  which 
in  turn  must  have  still  wider  applications. 

All  this  concerns  you  who  are  just  entering  on  your  life  work.  You 
can  receive  direct  benefits  and  enjoy  new  privileges  by  reason  of  these 
greater  opportunities,  but  they  also  bring  to  you  fresh  responsibilities. 

So  far  as  any  of  you  look  upon  these  foundations  from  without  it  is 
my  hope  that  some  things  have  been  said  which  will  rouse  in  you  a 
sympathetic  appreciation  of  the  kind  of  work  which  I  have  sought  to 
emphasize  as  the  most  precious  type  of  endeavor,  for  further  progress 
will  depend  largely  on  the  appreciation  and  support  given  to  this  by  the 
best  elements  in  the  medical  profession. 

The  material  side  of  our  advancing  civilization  has  developed  dur- 
ing a  thousand  years  to  an  astonishing  degree,  but  we  must  not  be  mis- 
led, as  sometimes  happens,  into  confusing  material  developments  with 
intellectual  progress.  These  foundations  of  to-day  are  but  aids  to  active 
minds  that  use  them.  The  mind,  the  man,  is  the  essential  thing,  and 
any  device  which  does  not  improve  him  and  give  him  the  very  best  oppor- 
tunity to  increase  his  powers,  has  but  slight  claim  to  our  regard.  I 
desire,  therefore,  to  leave  with  you  a  strong  impression  of  the  para- 
mount importance  of  our  mental  attitude  in  establishing  the  right  rela- 
tions between  research  foundations  and  medicine. 

Permit  me  then  in  closing  to  quote  a  little  fable  from  Luqman,  as 
it  seems  to  emphasize  this  point.  Luqman,  the  sage,  was  reputed,  I  am 
told,  to  have  been  either  an  Abyssinian  slave  of  King  David  or  the  son 
of  Job's  maternal  aunt.  That  question  is  not  settled — but  his  fable  has 
a  pleasant  oriental  flavor.     It  runs  as  follows : 

In  the  heat  of  the  day  the  lion  retired  to  a  cave.  While  resting 
there  a  rat  ran  over  him.  The  lion  jumped  up  in  fright,  whereat  the 
jackal  laughed.  Perceiving  this,  the  lion  said,  "I  was  not  frightened 
at  the  rat,  but  at  my  own  alarm  " ;  thus  showing  that  to  the  mighty  their 
state  of  mind  is  of  more  moment  than  death  itself. 


IMAGIXATIO]S"   AND    IDEALISM   IN   THE 
MEDICAL    SCIENCES^ 

By  the  late  Christian  A.  Herter,  M.D., 
Formerly  Professor  of  Pharmacology,  Columbia  University 

The  presidential  invitation  in  response  to  which  I  am  about  to 
address  you  to-day  was  welcome  to  me  because  it  offered  a  rare  chance 
to  express  some  views  of  medical  progress  which  I  think  are  too  seldom 
presented  to  the  student.  I  have  in  mind  the  infiuence  of  imagination 
and  idealism  on  the  growth  of  medical  discovery.  Vividly  recalling,  as 
I  do,  the  experiences  of  my  own  student  days,  more  than  a  quarter 
century  past,  I  fancy  you  as  coming  to  the  acquisition  of  the  myriad 
facts  of  medicine  with  little  to  tell  you  of  the  intellectual  forces  and 
historical  sequences  by  which  those  facts  have  emerged.  If  this  surmise 
be  correct,  it  follows  that  you  incline  to  take  a  static  rather  than  a 
dynamic  view  of  the  nature  of  scientific  medicine,  in  the  sense  that  you 
regard  medical  lore  as  something  much  more  fixed  than  is  actually  the 
case.  In  reality,  our  science  is  fortunately  plastic,  constantly  subject 
to  revision  of  its  facts,  and  ever  ready  to  welcome  new  interpretations 
of  old  facts  as  well  as  new  discoveries,  both  great  and  small.  This  very 
plasticity  it  is  that  makes  progress  attainable  and  fascinates  our  minds. 
But  our  text-books  and  our  lectures  are  necessarily  conservative  and 
dispose  us  strongly  to  the  notion  of  fixity  of  facts,  making  our  minds 
statical  in  conception.  I  would  like  to  dispel,  in  a  measure,  this  retard- 
ing conception  by  telling  you  something  of  the  ways  in  which  gifted 
and  trained  minds  have  enriched  the  medical  sciences  by  significant  dis- 
coveries. And  of  the  qualities  underlying  such  discoveries  I  would 
emphasize  especially  the  role  of  imagination  and  idealism. 

The  fine  humanitarian  aim  of  medicine  always  has  been  and  always 
will  be  one  of  the  features  that  make  men  love  to  practise  the  art.  And 
the  idealism  that  delights  in  the  relief  of  human  suffering  and  disability 
will  remain  alive  so  long  as  the  healing  art  itself.     But  we  must  not 

1  An  Address  Delivered  to  the  College  of  Physicians  and  Surgeons,  Columbia 
University,  September  23,  1909,  at  the  Opening  of  the  Medical  School.  Pub- 
lished by  the  Press  of  the  American  Medical  Association. 

487 


488  MEDICAL  RESEABCE  AND  EDUCATION 

blind  ourselves  to  the  fact  that  this  very  attitude  of  eager  desire  to  help 
our  fellows  in  distress  is  a  source  of  weakness  as  well  as  a  pillar  of 
strength.  For  he  who  would  answer  the  calls  of  the  sick  must  resort 
to  direct  methods  and  must  generally  tread  the  paths  of  the  obvious. 
He  has  not  time  to  turn  aside  to  the  indirect  ways  of  winning  the 
citadel,  nor,  indeed,  is  he  likely  to  be  in  that  frame  of  mind  which  urges 
to  such  an  approach;  he  is  preoccupied  with  the  crying  needs  of  the 
suffering  or  dying  man  committed  to  his  charge.  Yet  it  is  growing 
'  every  day  clearer  that  the  progress  of  the  medical  sciences  depends  in  a 
remarkable  degree  on  discoveries  made  by  indirect  methods — that  is,  by 
methods  not  looking  to  the  immediate  relief  of  disease. 

These  discoveries  are  made  chiefly  by  men  who,  while  in  deep  sym- 
pathy with  the  humanitarian  aims  of  medicine,  nevertheless  find  time  to 
turn  aside  to  studies  and  experiments  from  which  the  active  practi- 
tioners are,  in  general,  excluded,  by  the  circumstances  of  their  lives  and 
the  intensely  practical  nature  of  their  vocation.  There  was  a  time  when 
the  alert  physician  or  surgeon,  with  little  or  no  training  in  the  experi- 
mental method,  might  make  important  contributions  to  knowledge  by 
following  rather  evident  suggestions  derived  from  the  study  of  patients. 
The  Eomans,  operating  for  stone  in  the  bladder;  Pare,  using  the 
ligature  to  check  hemorrhage  on  the  field  of  battle;  McDowell,  success- 
fully removing  ovarian  tumors,  give  us  examples  of  great  advances 
along  rather  obvious  lines  of  development.  To-day  the  chances  for 
significant  progress  in  such  evident  directions,  although  not  exhausted, 
are  far  less  frequent.  The  golden  nuggets  at  or  near  the  surface  of 
things  have  been  for  the  greater  part  discovered,  it  seems  safe  to  say. 
"We  must  dig  deeper  to  find  new  ones  of  equal  value,  and  we  must  often 
dig  circuitously.  Math  mere  hints  for  guides.  Our  most  effective  tools 
are  to  be  found  in  the  experimental  laboratory,  where  the  fundamental 
sciences,  physics  and  chemistry,  come  to  the  aid  of  physiology,  biology, 
pathology  and  psychology.  I  should  like  to  tell  you  of  some  of  the 
many  instances  in  which  these  sciences  have  come  to  the  succor  of 
medicine  and  have  brought  her  riches  of  knowledge  unattainable  had 
she  been  limited  to  resources  belonging  to  the  accumulated  experience 
which  makes  up  the  accepted  material  of  medical  teaching.  If  I  inci- 
dentally say  something  of  the  personality  of  the  men  who  have  been  the 
living  instruments  of  this  progress,  it  is  in  order  to  give  you  occasional 
glimpses  into  the  workings  of  some  of  the  most  original  and  productive 
of  minds. 


IMAGINATION   AND    IDEALISM  489 

I  like  to  think  of  medicine  in  onr  clay  as  an  ever-broadening  and 
deej^ening  river,  fed  by  the  limpid  streams  of  pure  science.  The  river 
at  its  borders  has  its  eddies  and  currents,  expressive  of  certain  doubts 
and  errors  that  fringe  all  progress ;  but  it  makes  continuous  advances  on 
the  way  to  the  ocean  of  its  destiny.  Very  gi-adual  has  been  the  progress 
of  its  widening  and  deepening,  for  it  is  a  product  of  human  ingenuity 
and  artifice,  and  only  skilled  engineers  could  direct  the  isolated  currents 
of  science  into  the  somewhat  sluggish  stream  of  medical  utility.  The 
names  of  some  of  the  greatest  of  these  engineers  are  familiar  to  you — 
Yesalius,  Harvey,  Malpighi,  John  Hunter,  Claude  Bernard,  Helmholtz, 
Virchow,  Metchnikoff,  Pasteur,  Lister,  Koch,  Behring,  Ehrlich,  Emil 
Fischer,  Weigert,  Wright,  Theobald  Smith,  Flexner.  Different  as  have 
been  the  achievements  of  these  men,  there  are  some  qualities  of  mind 
and  of  heart  which  nearly  all  of  them  have  shown  in  ample  measure,  and 
of  such  qualities  none  are  more  evident  than  imagination,  or  play  of 
fancy,  and  personal  idealism,  using  the  latter  term  to  mean  a  readiness 
to  make  sacrifices  for  the  sake  of  lofty  achievement.  And  I  think  we 
are  quite  safe  in  making  the  generalization  that  the  discoveries  for 
which  we  hold  these  thinkers  in  honor  would  have  been  impossible  but 
for  the  exercise  of  these  qualities.  If  this  be  true,  the  fact  furnishes  us 
with  a  clue  to  present  tendencies  in  medicine  and  shows  us  to  what  sorts 
of  gifts  we  have  to  look  for  the  significant  advances  of  the  future.  I, 
therefore,  hope  to  make  good  my  generalizations  by  a  series  of  examples. 

If  we  look  over  any  list  of  the  names  of  the  makers  of  modern  medi- 
cine, we  shall  find,  that  they  may  be  classed  in  two  main  and  definite 
groups,  according  to  the  intellectual  trend  for  which  they  stand.  One 
group  holds  the  men  who  look  at  the  problems  of  medical  science  largely 
from  the  standpoint  of  structure  and  arrangement.  They  have  the 
instincts  and  interests  of  the  morphologists.  They  represent  anatomy, 
embryology,  pathological  anatomy  and  histolog}\  They  have  usually 
been  men  of  powerful  and  logical  minds,  craving  the  positive,  the 
definite  and  the  attainable,  either  shunning  somewhat  the  speculative 
aspects  of  science,  or  moving  uncomfortably  in  the  midst  of  ill-defined 
or  challengeable  facts.  In  this  list  belong  Yesalius,  von  Baer,  Bichat, 
Virchow  and  Weigert,  who  represent  with  maximal  distinction  the 
group  of  investigators  with  dominant  morphological  tendencies. 

In  sharp  contrast  with  this  definite  type  stands  the  second  group, 
made  up  of  men  whose  interests  lie  in  the  study  of  function,  rather 


\. 


490  MEDICAL  EESEARCH  AND  EDUCATION 

than  structure,  and  whose  minds,  far  from  being  dismayed  by  the 
speculative  aspects  of  their  studies,  invite  such  speculation  so  long  as 
it  is  severely  controlled  by  frequent  appeals  to  facts  won  by  experiment. 
The  members  of  this  small  group  are  dynamically  minded,  highly 
imaginative,  delighting  in  the  play  of  forces.  They  are  essentially 
experimentalists,  and  their  thoughts  in  leisure  hours,  as  in  the  hours 
of  work,  turn  always  restlessly  and  uncontrollably  in  the  same  direction 
■ — to  the  planning  of  new  experiments  designed  to  answer  the  questions 
uppermost  in  consciousness,  questions  having  nearly  always  to  do  with 
the  phenomena  of  living  beings.  Claude  Bernard,  Helmholtz,  Pasteur 
and  Ehrlich  are  the  unexcelled  prototypes  of  investigators  of  life- 
phenomena  in  medicine,  and  we  shall  not  go  far  astray  if  we  fancy  them 
as  spirits  inspired  by 

All  that  is  great  and  all  that  is  strange 
In  the  boundless  realm  of  unending  change. 

We  have  also,  I  think,  to  recognize  an  intermediate  group  of  great 
investigators  who,  while  highly  trained  in  a  morphological  way,  have 
shown  also  a  deep  and  productive  interest  in  the  functional  aspects  of 
organized  nature,  without,  however,  attaining  the  highest  levels  of 
achievement  in  thought  on  the  dynamical  side  of  medical  research.  In 
this  category  we  may  place  Harvey,  Malpighi,  John  Hunter,  Johannes 
Miiller,  Cohnheim  and  Robert  Koch.  And  I  think  we  may  safely  add 
that  most  modern  investigators,  educated  under  the  influence  of  the 
strong  trend  to  physiological  thought,  belong  in  this  intermediate 
position. 

The  examples  of  medical  discovery  which  I  shall  first  bring  to  your 
notice  I  shall  select  from  the  first  and  intermediate  groups  of  workers, 
reserving  the  illustrations  from  the  second  group  for  subsequent  con- 
sideration. 

The  first  great  morphologist  of  modern  times  is  Vesalius,  whose 
claims  to  recognition  rest  not  merely  on  his  masterly  and  precise  descrip- 
tion of  the  parts  of  the  human  body,  but  also  on  his  abrupt  departure 
from  the  Galenic  traditions  and  teachings,  forced  on  him  by  the  objec- 
tivity and  sincerity  of  his  studies.  While  we  must  regard  the  work  of 
Vesalius  as  evidence  of  intellectual  and  logical  power,  it  would  be  an 
error  to  credit  him  with  the  highest  type  of  imagination  or  with  elabo- 
rate esthetic  reactions.  The  self-willed,  clear-thinking  man  won  his 
triumphs  more  by  force  of  character  and  unswerving  purpose  than  by 


IMAGINATION   AND    IDEALISM  49l 

creative  intellect;  and  we  see  this  type  of  worker  repeated  in  some  of 
our  greatest  modern  anatomists,  as  also  in  some  fields  in  which  the 
experimental  method  is  prominent. 

The  idealism  which  inspired  Yesalius  was  not  proof  against  exasper- 
ations and  discouragements  due  to  the  hostility  of  the  Catholic  church 
to  all  research  on  the  human  hody.  After  destroying  valuable  manu- 
scripts and  resigning  his  professorship,  the  great  anatomist  attached 
himself  to  the  court  of  the  Emperor  Charles  V  and  aftei-ward  to  that  of 
Philip  II.  But  power  and  position  and  wealth  did  not  repay  him  for 
the  loss  of  intellectual  freedom  which  such  associations  imposed,  and 
for  some  reason  he  left  Spain  to  visit  the  Holy  Land.  It  is  said  that 
the  pilgrimage  was  made  in  penance  for  an  autopsy  performed  on  a 
young  woman  not  quite  dead;  and  Edith  Wharton  has  seized  on  the 
story  to  enrich  her  admirable  Browning-like  poem,  "Vesalius  in 
Zante": 

The  girl  they  brought  me,  pinioned  hand  and  foot 

In  catalepsy — say  I  should  have  known 

That  trance  had  not  yet  darkened  into  death, 

And  held  my  scalpel.    Well,  suppose  I  knew? 

Sum  up  the  facts — her  life  against  her  death. 

Her  life?     The  scum  upon  the  pools  of  pleasure 

Breeds   such   by  thousands.     And   her   death?     Perchance 

The  obolus  to  appease  the  ferrying  Shade, 

And  waft  her  into  immortality. 

Think  what  she  purchased  with  that  one  heart-flutter 

That  whispered  its  deep  secret  to  my  blade! 

Ah,  no!      The  sin  I  sinned  was  mine,  not  theirs. 

Not  that  they  sent  me  forth  to  wash  away — 

None  of  their  tariffed  frailties,  but  a  deed 

So  far  beyond  their  grasp  of  good  or  ill 

That,  set  to  weigh  it  in  the  Church's  balance, 

Scarce  would  they  know  which  scale  to  cast  it  in. 

But  I,  I  know.     I  sinned  against  my  will, 

Myself,  my  soul,  the  God  within  the  breast ; 

Can  any  penance  wash  such  sacrilege? 

How  vividly  and  how  justly  these  verses  paint  the  remorse  that  came 
from  adandonment  of  ideals,  when  the  young  investigator,  not  yet  thirty 
years  of  age,  exchanged  the  inner  satisfaction  of  legitimate  work  for  the 
prestige  of  courts ! 

But  Yesalius  in  that  short  span  of  work  had  founded  anatomv,  and 
Eustachius  and  Fallopius,  his  successors,  united  their  influence  with  his 
(despite  some  disloyalties  and  antagonisms)  to  establish  the  scientific 


492  MEDICAL  BESEAECH  AND  EDUCATION 

method  in  this  branch  of  learning.  The  future  of  anatomy  in  Europe 
seemed  assured.  This  gain  in  scientific  method,  initiated  by  Vesalius, 
was  fixed  and  established  in  England  by  the  spirited,  penetrating  and 
imaginative  William  Harvey,  whose  monumental  work  proved  that  all 
the  blood  in  the  body  travels  in  a  circuit  impelled  by  the  beating  of  the 
heart.  That  a  highly  skilled  anatomist  should  have  made  this  physio- 
logical discovery  is  significant  evidence  that  studies  in  structure  may 
stimulate  a  labile  mind  to  serious  investigation  of  the  functional  side  of 
organic  nature.  Probably  the  work  which  Harvey  did  with  his  master, 
Fabricius,  at  Padua  in  the  anatomy  of  the  vascular  system  stimulated 
his  interest  in  the  discovery  of  experimental  methods  which  should 
expose  the  true  uses  of  this  elaborate  mechanism.  And  the  same 
ingenuity  which  led  to  such  conspicuous  success  in  physiological  research, 
the  same  interest  in  the  vital  phenomena,  caused  Harvey  to  ponder  and 
study  the  mysteries  of  development  in  the  chick,  the  deer  and  other 
mammals.  These  embryological  observations  are  of  such  a  grade  of 
excellence  that  some  of  the  greatest  biologists  regard  them  as  superior 
in  quality  to  the  immortal  studies  of  the  circulation. 

The  lofty  intellect  of  Harvey  was  linked  with  a  generous  and 
idealistic  nature.  His  portraits  show  a  formation  of  head  and  face  that 
reminds  us  of  representations  of  Shakespeare.  Like  Hunter  and 
Darwin,  he  had  the  virtue  of  being  extremely  slow  in  publishing.  He 
forgave  his  many  antagonists,  notwithstanding  the  troubles  they  brought 
into  his  life.    He  says: 

I  would  not  charge  with  wilful  falsehood  any  one  who  was  sincerely  anxious 
for  truth,  nor  lay  it  to  any  one's  door  as  a  crime  that  he  had  fallen  into  error. 
I  am,  myself,  the  partisan  of  truth  alone;  and  I  can  indeed  say  that  I  have 
used  all  my  endeavors,  bestowed  all  my  pains  on  an  attempt  to  produce  some- 
thing that  should  be  agreeable  to  the  good,  profitable  to  the  learned,  and  use- 
ful to  letters. 

More  than  a  hundred  years  after  the  death  of  Harvey  there  emerged 
from  obscurity  a  Scotchman,  John  Hunter,  of  such  power  and  versatility 
as  to  make  him  a  worthy  intellectual  successor  of  the  great  Englishman. 
"We  may  take  him  as  our  second  example  of  an  investigator  of  our 
intermediate  group,  combining  the  interests  of  morphologist  and 
physiologist.  Of  his  works  as  anatomist  and  surgeon  and  comparative 
anatomist,  I  shall  say  nothing  here.  The  wonderful  Hunterian  Museum 
of  London  is  a  peerless  monument  to  the  labors  of  the  anatomist  and 
surgeon.     But  it  does  not  especially  direct  our  thoughts  to  his  physio- 


IMAGINATION   AND    IDEALISM  493 

logical  and  experimental  way  of  thinking,  which  we  may  safely  con- 
sider his  strongest  claim  to  greatness.     One   examjDle — a   celebrated 
instance — will  illustrate  the  point  I  wish  to  make.    It  was  in  Richmond 
Park  that  Hunter  saw  the  deer  whose  growing  antlers  awakened  in  his 
mind  a  singularly  fruitful  physiological  question.    What  would  happen  if 
he  shut  off  the  blood-supply  of  the  antler  on  one  side  by  tying  the  corre- 
sponding carotid  artery?     Experiment  showed  that  the  antler  lost  its 
warmth  and  ceased  to  grow;  but  for  a  short  time  only  was  there  this 
check  to  growth.    After  a  time  the  horn  warmed  again  and  grew.    Had 
he  failed  to  really  obstruct  the  blood  flow  in  the  artery  ?    No.    Examina- 
tion showed  the  carotid  to  have  been  securely  ligated.     Whence,  then, 
came  the  blood  essential  for  the  antlei-^s  growth  ?    Through  the  neigh- 
boring arteries  that  had  grown  distended,  through  what  we  now  call 
the  collateral  circulation.     So  was  the  fact  of  the  collateral  circulation 
revealed.     The  thoughtful  and  logical  mind  of  the  practical  surgeon 
soon  found  an  important  application  of  this  discovery  to  human  pathol- 
ogy.   No  one  had  dared  to  treat  aneurism  by  ligation  for  fear  of  causing 
gangrene.    But  the  existence  of  a  collateral  circulation  held  out  a  pros- 
pect of  keeping  the  parts  alive  despite  the  ligation  of  an  important 
artery.     The  first  trial  of  the  new  method  on  a  popliteal  aneurism  was 
successful,  and  the  Hunterian  operation,  as  you  know  it  in  surgery  to- 
day, came  into  assured  existence.     An  unimaginative  man  could  not 
have  made  this  discovery  in  this  manner.     Yet  Hunter  belongs  to  the 
logical,  independent,  matter-of-fact  type  with  fancy  well  controlled, 
rather  than  to  the  dreamers  and  poets  of  science.     He  was  a  rough 
diamond,  with  an  intensely  objective  nature,  and  he  had  corresponding 
limitations.    He  is  said  to  have  rebelled  against  the  classical  teachings 
of  Oxford.     "Why,  they  wanted  me  to  study  Greek.     They  wanted  to 
make  an  old  woman  of  me  !  "    And  when  twitted  with  his  lack  of  knowl- 
edge of  the  "  dead  languages  "  he  said  of  his  critic :  "  I  could  teach  him 
that  in  the  dead  body  which  he  never  knew  in  any  language,  living  or 
dead."    The  idealism  of  Hunter  showed  itself  in  devotion  to  work  and 
in  fortitude  in  the  adversity  of  ill  health. 

I  wish  now  to  invite  your  attention  to  our  second  type  of  investigator 
— the  essentially  dynamical  or  physiological  discoverer.  The  group,  as 
I  see  it,  is  a  small  one.  It  includes  Claude  Bernard,  Louis  Pasteur, 
Hermann  von  Helmholtz  and  Paul  Ehrlich. 

An  admirer  said  sententiously  of  Bernard:  "He  is  not  merely  a 


494  MEDICAL   BESEABCH  AND  EDUCATION 

physiologist ;  he  is  physiology  itself  " ;  and  the  saying  has  the  merit  of 
reminding  us  of  the  breadth  and  depth  and  originality  of  his  researches. 
With  equal  skill  he  worked  at  the  physical  and  chemical  bases  of 
•  physiology ;  and  we  owe  to  him  our  knowledge  of  the  glycogenic  func- 
tion of  the  liver,  the  enzymes  of  the  pancreatic  juice,  the  vasomotor 
system  of  nerves,  diabetes  from  puncture  of  the  fourth  ventricle,  besides 
many  minor  discoveries  and  researches  and  a  masterly  correlation  of  the 
general  facts  of  animal  and  plant  life.  Bernard  was  one  of  the 
founders  of  modern  pharmacology.  He  also  foreshadowed  in  a  singular 
manner  and  under  singular  circumstances  the  modern  conception  of 
soluble  ferments  in  microorganisms,  a  view  which  unfortunately  brought 
him  into  an  unpleasant  antagonism  with  his  lifelong  friend,  Pasteur. 

The  research  that  most  fully  shows  the  controlled  imagination  of 
Bernard  is  that  which,  extending  over  years,  culminated  in  the  dis- 
covery of  the  glycogenic  function  of  the  liver,  a  discovery  of  the  very 
first  significance  to  physiology  and  pathology.  We  know  the  steps 
which  led  him  to  this  discovery,  and  in  retracing  these  steps  we  get  an 
edifying  glimpse  of  the  workings  of  Bernard's  fertile  mind.  His 
ambition  was  to  follow  the  three  great  classes  of  foodstuffs,  carbo- 
hydrates, fats  and  proteids,  through  the  organism.  He  soon  felt  the 
necessity  of  limiting  himself  to  the  fate  of  the  carbohydrates,  which, 
besides  seeming  relatively  simple  to  study,  especially  attracted  him  on 
account  of  their  mysterious  relation  to  diabetes.  The  first  step  in  the 
research  brought  out  the  fact  that  cane-sugar,  when  acted  on  by  gastric 
juice,  undergoes  a  transformation  which  adapts  it  for  absorption  and 
utilization  by  the  tissues — namely,  a  change  into  dextrose  (glucose). 
He  knew  from  the  experiments  of  Tiedemann  that  starch  is  changed 
into  dextrose  in  the  digestive  tract  before  absorption.  Bernard  asked 
himself  what  was  the  fate  of  this  dextrose.  He  proposed  to  trace  the 
course  of  the  sugar  from  the  digestive  tract,  along  the  portal  vein  to  the 
liver,  from  the  liver  to  the  lungs  by  way  of  the  right  heart,  and  finally 
from  the  lungs  through  the  left  heart  to  the  various  tissues.  His  idea 
was  that  at  one  of  these  stations  the  dextrose  disappears,  is  destroyed  or 
in  some  manner  changed.  "  If  I  am  able,"  said  he,  "  to  suppress  the 
activity  of  this  station,  sugar  will  accumulate  in  the  blood  and  a  condi- 
tion of  diabetes  will  be  brought  about."  Here,  then,  was  a  highly 
interesting  enterprise.  The  first  thing  to  do  was  to  feed  a  dog  freely 
on  carbohydrates,  kill  it  at  the  height  of  digestion  and  examine  the 


IMAGINATION   AND    IDEALISM  495 

blood  leaving  the  liver  by  the  hepatic  veins  to  see  if  any  sugar  were  lost 
in  the  liver.  Please  note  that  Bernard  was  helped  in  this  search  for 
sugar  in  the  blood  and  tissues  by  the  cupric  sulphate  test  for  dextrose, 
just  introduced  by  his  friend,  Barreswill — a  very  material  help.  Sugar 
was  found  in  abundance  in  the  blood  of  the  hepatic  veins;  therefore, 
the  liver  was  not  the  looked-for  place  of  disappearance  of  dextrose. 
"  But  how  do  I  know,"  thought  Bernard,  "  that  the  sugar  which  I  thus 
find  in  the  hepatic  vein  is  the  same  sugar  as  that  which  I  introduced 
into  the  portal  blood  through  the  food  ?  "  To  get  an  answer,  Bernard  fed 
a  dog  on  meat  only,  knowing  by  experiment  that  no  dextrose  would  then 
be  present  either  in  the  digestive  tract  or  in  the  portal  blood.  Then  he 
examined  the  blood  of  the  hepatic  vein  for  sugar.  Great  was  his  sur- 
prise to  find  it  loaded  with  dextrose.  His  keen  intelligence  at  once  drew 
the  correct  inference — that  the  liver  is  a  sugar-making  organ  and  makes 
sugar  out  of  something  which  is  not  sugar,  and,  furthermore,  that  within 
the  liver  lies  the  secret  of  diabetes.  Bernard  now  made  a  variety  of 
experiments  to  test  the  correctness  of  his  inferences.  He  soon  found 
that  sugar  was  contained  in  a  simple  decoction  of  the  liver  and  that 
this  sugar  was  dextrose,  capable  of  fermentation  and  responding  to  all  the 
known  tests.  But  Bernard  did  not  stop  here.  His  fancy  urged  him  to 
seek  the  substance  in  the  liver  from  which  the  sugar  is  produced — the 
"gtycogenic  substance"  whose  existence  was  inferred  from  experiment. 
And  in  time  he  isolated  the  substance  which  we  know  to-day  as  glycogen. 

Here,  then,  was  a  great  triumph  of  the  experimental  method  in  the 
hands  of  an  imaginative,  critical  and  highly  skilled  technical  worker. 
The  completeness  with  which  the  discovery  of  the  glycogenic  function 
of  the  liver  was  worked  out  makes  it  a  model  of  physiological  research 
for  all  time.  Moreover,  the  facts  elicited  by  Bernard  in  this  research 
possess  a  very  broad  bearing.  They  show  that  the  liver  has  a  function 
as  important  as,  but  far  less  obvious  than,  the  secretion  of  bile — the 
first  example  of  an  internal  secretion.  And  they  prove  that  animals  as 
well  as  plants  can  build  up  carbohydrate  material— glycogen— by  means 
of  their  own  tissues.  Finally  Bernard  very  clearly  showed  that,  while 
the  production  of  glycogen  from  sugar  is  a  vital  act,  in  the  sense  of 
occurring  only  under  conditions  of  life,  the  converse  process,  namely, 
the  formation  of  sugar  from  glycogen,  is  independent  of  living  tissues 
and  may  occur  as  the  result  of  the  action  of  a  ferment  in  the  blood. 

As  Sir  Michael  Foster  said  most  aptly : 


496  MEDICAL  EESEAECH  AND  EDUCATION 

It  is  in  the  putting  forth  of  the  hypothesis  that  the  true  man  of  science 
shows  the  creative  power  which  makes  him  and  the  poets  brothers.  His  must  be 
a  sensitive  soul,  ready  to  vibrate  to  Nature's  touches.  Before  the  dull  eye  of 
the  ordinary  mind  facts  pass  one  after  the  other  in  long  procession,  but  pass 
without  effect,  awakening  nothing.  In  the  eye  of  the  man  of  genius,  be  he 
poet  or  man  of  science,  the  same  facts  light  up  an  illumination,  in  the  one  of 
beauty,  in  the  other  of  truth;  each  possesses  a  responsive  imagination.  Such 
had  Bernard,  and  the  responses  which  in  his  youth  found  expression  in  verses  in 
his  maturer  and  trained  mind  took  the  form  of  scientific  hypothesis. 

That  Bernard  well  understood  the  value  of  imagination  in  research 
and  also  its  dangers  is  well  shown  by  his  admirable  and  memorable 
advice  to  his  pupils : 

Put  off  your  imagination  as  you  take  off  your  overcoat  when  you  enter  the 
laboratory;  but  put  it  on  again,  as  you  do  your  overcoat,  when  you  leave  the 
laboratory.  Before  the  experiment  and  betweenwhiles  let  your  imagination 
wrap  you  round;  put  it  right  away  from  yourself  during  the  experiment  itself, 
lest  it  hinder  your  observing  power. 

The  dramatic  and  poetic  instincts  were  strong  in  Bernard.  He 
composed  a  vaudeville  comedy  called  "The  Eose  of  the  Rhone/'  and 
later  a  metrical  tragedy  which  he  altered  to  a  prose  drama.  But  the 
love  of  analysis  and  of  original  research  triumphed  over  these  esthetic 
tendencies  of  Bernard's  nature,  and  in  the  reserved  and  inhibited  per- 
sonality and  somewhat  cold  intellectuality  of  his  maturer  years  it  was 
not  always  easy  to  detect  this  underlying  esthetic  and  emotional  trait. 
His  married  life  did  not  bring  him  happiness,  as  his  wife  sought  dis- 
play and  material  successes  and  was  unable  to  understand  the  purity  of 
purpose  from  which  he  never  swerved  in  the  long  career  to  which 
physiology  owes  so  great  a  debt. 

Let  us  now  bring  to  your  attention  some  features  of  the  mental  life 
of  another  great  physiologist,  Hermann  von  Helmholtz,  representing 
a  very  different  phase  of  physiology  from  that  developed  by  Bernard. 
Bernard,  though  accomplished  as  a  morphologist  and  skilled  in  mechan- 
ical physiology,  leaned  strongly  to  the  chemical  side.  He  was  essentially 
the  animal  experimentalist.  Mathematics  played  only  the  most  simple 
role  in  his  researches.  Helmholtz,  on  the  other  hand,  approached  physi- 
ology on  its  physical  side,  and,  one  may  remark  in  passing,  with  a 
quality  and  amplitude  of  success  unequaled  before  or  since.  He  used 
the  higher  mathematics  constantly  and  they  proved  keen  tools  in  his 
hands.  Although  an  experimentalist  of  the  very  first  order,  Helmholtz 
was  not  an  animal  experimenter  except  in  a  very  limited  way,  the 
nature  of  his  themes  making  vivisection  for  the  most  part  unnecessary. 


J 


IMAGINATION   AND    IDEALISM  497 

Even  as  a  child  the  mind  of  Helmholtz  was  unconventional  and 
inquiring,  bent  on  understanding  what  was  going  on  about  him.  The 
boy  cut  his  own  path  through  the  mazes  of  unassimilable  educational 
offerings.  His  tastes  were  definite.  He  obtained  notions  of  geometry 
from  the  blocks  with  which  he  played,  surprised  his  mother  by  experi- 
menting on  her  linen  with  acids,  made  telescopes  with  spectacle  lenses, 
read  books  on  physics  and  enjoyed  greatly  his  walks  in  the  country.  At 
the  university  he  assimilated  ideas  with  great  ease  and  showed  an  in- 
creasing interest  in  physics,  which  he  wished  to  follow  as  a  profession. 
But  his  prudent  father  urged  him  to  study  medicine  as  a  surer  means 
of  livelihood.  And  most  fortunate  it  was  for  medical  science  that  the 
gifted  young  man  was  willing  to  take  up  medical  studies,  for  there 
arose  in  him  a  deep  interest  in  the  problems  of  physiology,  destined  to 
bear  rich  fruit.  The  duties  of  an  army  surgeon  took  only  part  of  his 
time  and  the  rest  he  gave  to  physics.  His  original  researches  began  at 
the  age  of  21  and  continued  through  a  long  lifetime,  covering  an  ex- 
traordinary range  of  topics  in  an  original  and  masterly  way.  Helmholtz 
contributes  to  minute  anatomy,  lays  the  foundations  of  physiological 
optics  and  acoustics  (with  all  that  this  means  for  esthetics,  psychology 
and  metaphysics),  gives, to  medicine  the  specific  and  golden  gift  of  the 
ophthalmoscope,  enriches  physics  with  an  imperishable  statement  of  the 
doctrine  of  the  conservation  of  energy  and  with  original  studies  on 
vortex  motion,  on  hydrodynamics,  on  electrodynamics,  on  dynamics,  on 
meteorological  physics.  He  broadens  chemical  theory  by  the  influence 
of  his  vortex  motion  hypothesis  and,  in  a  somewhat  incidental  way, 
brings  new  theoretical  conceptions  into  the  realm  of  pure  mathematics. 
As  students  of  the  psychical  forces  that  have  fertilized  modern  medicine 
it  is  interesting  for  us  to  note  that  Helmholtz  disclaimed  any  intention 
to  be  practical  in  his  work.  If  the  themes  that  happened  to  absorb  his 
attention  led  to  practical  and  humanly  useful  results,  he  was  pleased; 
but  he  seldom  pursued  a  practical  aim  simply  because  of  its  utility.  He 
chose  his  themes  because  they  promised  to  be  intellectually  satisfying, 
giving  little  heed  to  the  nature  of  the  probable  outcome.  He  framed 
his  experiments  so  that  Nature  would  have  to  answer  "  Yes  "  or  "  No  " 
to  his  questions,  thus  furnishing  him  with  definite  results. 

The  story  of  the  invention  of  the  oplithalmoscope  illustrates  the 
mental  processes  of  Helmholtz  in  working  out  an  idea.  He  did  not  set 
out  to  de\dse  an  instrument  for  studying  the  retina  and  the  ocular 

33 


498  MEDICAL  EESEABCH  AND  EDUCATION 

refraction,  but  as  he  proceeded  these  important  possibilities  ripened  into 
definite  objects.    He  says : 

I  was  endeavoring  to  explain  to  my  pupils  the  emission  of  reflected  light 
from  the  eye,  a  discovery  made  by  Briicke,  who  would  have  invented  the  ophthal- 
moscope had  he  only  asked  himself  how  an  optical  image  is  formed  by  the  light 
returning  from  the  eye.  In  his  research  it  was  not  necessary  to  ask  it,  but  had 
he  asked  it,  he  was  just  the  man  to  answer  it  as  quickly  as  I  did,  and  to  invent 
the  instrument.  I  turned  the  problem  over  and  over  to  ascertain  the  simplest 
way  in  which  to  demonstrate  the  phenomenon  to  my  students.  It  was  also  a 
reminiscence  of  my  days  of  medical  study,  that  ophthalmologists  had  great  diffi- 
culty in  dealing  with  certain  cases  of  eye  disease,  then  known  as  black  cataract. 
The  first  model  was  constructed  of  pasteboard^  eye  lenses,  and  cover-glasses  used 
in  the  microscopic  work.  It  was  at  first  so  difficult  to  use  that  I  doubt  if  I 
should  have  persevered,  unless  I  had  felt  that  it  must  succeed;  but  in  eight  days 
I  had  the  great  joy  of  being  the  first  who  saw  before  him  a  human  retina. 

The  basis  for  this  invention  was  Helmholtz's  knowledge  of  the  anat- 
omy of  the  eye,  his  mastery  of  physiological  optics,  his  experimental 
ability,  and,  as  stated  in  his  own  language,  his  wish  to  devise  an  im- 
proved method  of  demonstrating  a  somewhat  obscure  phenomenon  to 
his  students.  Modesty  and  generous  impulse  made  Helmholtz  say  that 
Briicke  could  equally  well  have  invented  the  ophthalmoscope  had  he 
only  asked  himself  how  an  optical  image  is  formed  by  the  light  return- 
ing from  the  eye.  I  doubt  if  it  could  be  successfully  contended  that 
Briicke's  actual  information  about  the  eye  was  less  than  Helmholtz's. 
Helmholtz  himself  says  that  Briicke  "was  just  the  man"  to  make  the 
invention,  and  by  this  he  must  refer  to  equipment  in  knowledge.  In 
what,  then,  did  Helmholtz  excel  Briicke?  I  would  answer,  in  creative 
fancy,  in  imagination.  The  controlled  play  of  fancy,  using  the  facts  of 
the  case  for  its  playground,  is  what  made  Helmholtz  see  the  possibilities 
and  see  them  so  clearly  as  also  to  make  it  appear  worth  while  to  put 
energy  into  the  effort  to  see  the  retina. 

It  would  be  easy  to  multiply  examples  of  the  almost  playful  way  in 
which  Helmholtz  utilized  the  children  of  his  rich  fancy  to  extend  the 
bounds  of  scientific  knowledge.  The  ease  with  which  he  made  his 
intellectual  progress  is  one  of  the  most  striking  features  of  his  wonder- 
fully creative  career.  Often  on  solitary  walks  in  the  country  he  experi- 
enced ideas  that  seemed  to  clarify  refractory  problems.  From  the 
great  wealth  of  his  impressions  and  associated  ideas,  arising  through  the 
operation  of  active  fancy  or  imagination,  there  seems  to  have  been  a 
process  of  controlled  selection  and  rejection  by  which  the  finished  prod- 
ucts, the  great  ideas,  were  built  up — a  conscious  selection  not  without 


IMAGINATION   AND    IDEALISM  499 

analogies  to  natural  selection  in  the  upbuilding  of  the  physical  machin- 
ery. In  the  entire  list  of  the  masters  of  medicine  I  think  there  has  been 
only  one  mind  that  can  be  regarded  as  belonging  on  the  same  lofty  level 
as  that  of  Helmholtz,  in  respect  to  controlled  yet  expansive  powers  of 
imagination  combined  with  the  energy  of  performance  and  the  technical 
training  necessary  to  apply  those  powers.  The  intellect  of  Pasteur,  and 
his  alone,  has  revealed  associative  power  and  logical  sequences  of  thought 
culminating  in  discoveries  fairly  comparable  to  those  of  Helmholtz  in 
respect  to  the  depth  of  their  psychical  basis.  And  it  is  probably  no 
accident  that  the  two  greatest  minds  in  medicine  have  entered  it  on 
the  streams  of  pure  science,  Helmholtz  as  the  biological  physicist, 
Pasteur  as  the  biological  chemist. 

As  a  human  being  Helmholtz  takes  rank  with  the  noblest  of  men. 
Considerateness  for  others  and  a  willingness  to  help  worthy  persons  were 
prominent  characteristics.  He  had  a  calm  self-control  which  still  left 
him  natural  and  simple  in  human  relations,  although  this  fine  dignity 
served  as  a  check  to  the  approaches  of  shallow  and  trivial  people. 
Helmholtz  was  an  idealist  of  the  purest  type,  and  never  permitted 
personal  interest  to  interfere  with  his  best  aims  as  a  student  of  science. 
His  was  a  poetic  nature,  apt  in  versification  and  in  music,  yet  with  an 
intellect  so  searching  that  he  was  not  entirely  satisfied  by  esthetic  feel- 
ing and  phantasy,  but  sought  also  to  understand  them.  Modesty  was 
one  of  his  greatest  charms,  and  this  quality  was  attractively  seen  in  the 
sentiment  which  he  expressed  on  being  awarded  the  von  Graefe  medal  in 
recognition  of  his  services  to  medicine  through  the  invention  of  the 
ophthalmoscope : 

Let  us  suppose  that  up  to  the  time  of  Phidias  nobody  has  had  a  chisel  suffi- 
ciently hard  to  work  on  marble.  Up  to  that  time  they  would  only  mold  clay  or 
carve  wood.  But  a  clever  smith  discovers  how  a  chisel  can  be  tempered.  Phidias 
rejoices  over  the  improved  tools,  fashions  with  them  his  god-like  statues  and 
manipulates  the  marble  as  no  one  has  ever  before  done.  He  is  honored  and 
rewarded.  But  great  geniuses  are  modest  just  in  that  in  which  they  most  excel 
others.  That  very  thing  is  so  easy  for  them  that  they  can  hardly  understand  why 
others  can  not  do  it.  But  there  is  always  associated  with  high  endowments  a 
correspondingly  great  sensitiveness  for  the  defects  of  one's  own  work.  Thus, 
says  Phidias  to  the  smith,  "Without  your  aid  I  could  have  done  nothing  of 
that;  the  honor  and  glory  belong  to  you."  But  the  smith  can  only  answer  him, 
"But  I  could  not  have  done  it  even  with  my  chisels,  whereas  you,  without  my 
chisels,  could  at  least  have  molded  your  wonderful  works  in  clay;  therefore  I 
must  decline  the  honor  and  glory,  if  I  will  remain  an  honorable  man."  But 
now  Phidias  is  taken  away,  and  there  remain  his  friends  and  pupils— Praxiteles, 


500  MEDICAL   BESEAECH   AND    EDUCATION 

Paiouios  and  others.  They  all  use  the  chisel  of  the  smith.  The  world  is  filled 
with  their  work  and  their  fame.  They  determine  to  honor  the  memory  of  the 
deceased  with  a  garland  which  he  shall  receive  who  has  done  the  most  for  the 
art,  and  in  the  art,  of  statuary.  The  beloved  master  has  often  praised  the  smith 
as  the  author  of  their  great  success,  and  they  finally  decide  to  award  the  garland 
to  him.  "Well,"  answers  the  smith,  "I  consent;  you  are  many,  and  among  you 
are  clever  people.  I  am  but  a  single  man.  You  assert  that  I  singly  have  been 
of  service  to  many  of  you,  and  that  many  places  teem  with  sculptors  who  have 
decked  the  temples  with  divine  statues,  which,  without  the  tools  that  I  have  given 
you,  would  have  been  very  imperfectly  fashioned.  I  must  believe  you,  as  I  have 
never  chiseled  marble,  and  I  accept  thankfully  what  you  award  to  me,  but  I  my- 
self would  have  given  my  vote  to  Praxiteles  or  Paionios. " 

If  we  turn  now  to  Helmholtz's  great  contemporary,  Louis  Pasteur, 
we  discern  many  points  of  resemblance  in  the  mental  endowments  and 
in  the  careers  of  these  two  superlatively  eminent  masters  of  medical 
science.  Pasteur,  like  Helmholtz,  was  greatly  helped  in  early  life  by  the 
patient  guidance  of  earnest  and  capable  parents,  and,  like  him,  showed 
a  strong  interest  in  poetry  and  art,  the  portraits  made  by  Pasteur  during 
his  teens  showing  unmistakable  artistic  talent.  Pasteur's  considerable 
aptitude  for  mathematics  developed  later  than  that  of  Helmholtz  and 
was  of  a  less  original  sort,  yet  served  him  well,  especially  in  his  earlier 
researches.  Both  men  were  endowed  with  phantasy  and  associative 
power  of  the  highest  order,  but,  while  Helmholtz  seldom  departed  from 
the  path  of  strict  logical  development  of  his  ideas,  Pasteur,  with  his 
more  impetuous  nature,  sometimes  permitted  himself  to  make  specu- 
lative excursions  of  a  more  random  kind.  Both  found  their  greatest  en- 
joyment in  dealing  with  the  development  of  general  ideas,  but  Pasteur, 
on  realizing  his  power  to  help  mankind  through  his  discoveries,  delib- 
erately turned  his  rare  gifts  to  the  solution  of  practical  problems  in 
medicine,  whereas  Helmholtz  was  satisfied  to  continue  to  build  the 
foundations  for  the  physiology  of  the  sense  organs  and  for  a  better 
psychology  and  metaphysics.  It  is  very  noteworthy  that  both  Helm- 
holtz and  Pasteur  were  deeply  influenced  in  their  outlook  by  certain  con- 
ceptions of  wide  applicability.  Helmholtz  learned  from  his  great 
master,  Johannes  Miiller,  to  attach  great  importance  to  the  principle 
of  the  specificity  of  nerves — that  is,  the  doctrine  which  teaches  that 
nerves  of  special  sense,  as  the  optic  or  acoustic  nerves,  however  stimu- 
lated, respond  with  a  quite  specific  reaction,  with  sensations  of  light 
or  sensations  of  sound,  respectively.  This  principle  guided  Helmholtz 
not  alone  in  his  studies  of  the  physiology  of  the  special  senses,  but  in  his 
philosophical  attitude,  which  brought  him  into  collision  with  the  widely 


IMAGINATION   AND    IDEALISM  501 

accepted  metaphysics  of  Kant.     On  the  other  hand,  Pasteur's  scientific 
and  philosophical  thought  was  influenced  definitely  and  profoundly  by 
the  conception  of  molecular  asymmetry  in  nature.    His  interest  in  this 
subject  was  awakened  by  the  study  of  the  salts  of  tartaric  acid,  which 
culminated  in  1848  with  the  famous  discovery  that  the  optically  indiffer- 
ent or  racemic  tartaric  acid  crystallizes  into  equal  quantities  of  the 
ordinary  dextrorotary  tartaric  acid  and  of  the  newly  recognized  levo- 
rotary  tartaric  acid.    It  was  Pasteur's  interest  in  the  problem  of  molec- 
ular as^-mmetry,  and  especially  certain  theoretical  notions  on  which  we 
need  not  linger  here,  that  induced  him  to  experiment  on  the  action  of 
microorganisms  on  racemic  ammonium  tartrate,  with  the  striking  result 
that  the  living  beings  converted  the  optically  indifferent  solution  of  salts 
into  a  levorotary  solution.     This  showed  that  the  dextrorotary  con- 
stituent of  the  indifferent  racemic  tartrate  had  been  assimilated  by  the 
microorganisms,  while  the  levorotary  constituent  was  unaffected.     I 
emphasize  these  studies  of  Pasteur's  because  they  were  what  excited  his 
interest  in  the  then  obscure  problem  of  fermentation,  which  in  turn 
led  him  to  take  up  those  studies  of  the  causation  of  disease  by  micro- 
organisms and  those  researches  on  immunity  which  have  revolutionized 
the  entire  science  and  art  of  medicine.    To  do  anything  like  justice  to 
these  extraordinarily  fertile  and  original  researches  of  Pasteur  is  wholly 
out  of  the  question  here.    I  can  merely  direct  your  attention  to  the  re- 
searches which  in  the  fullest  way  exemplify  Pasteur's  gift  of  imagina- 
tion and  power  of  experimental  control.    There  are  six  studies  or  groups 
of  studies  whose  histories  exhibit  Pasteur's  genius  at  its  best — the 
research  on  the  tartrates,  the  investigations  on  fermentation,  the  inquiry 
into  the  causes  of  the  silkworm  disease,  and  the  methods  of  its  eradica- 
tion, the  research  on  chicken  cholera  and  immunity  to  it,  the  research  on 
anthrax,  with  the  extraordinarily  dramatic  scenes  attending  the  public 
test  of  the  immunization  methods,  and  finally  the  masterly  researches 
on  hydrophobia.    People  have,  in  general,  been  perhaps  most  impressed 
by  the  researches  on  hydrophobia.    Here  Pasteur  dealt  intimately  with 
a  disease  affecting  man.    The  horrible  effects  of  rabies  on  human  person- 
ality, the  publicity  of  the  first  daring  attempts  at  prevention  by  the  use 
of  attenuated  vinis,  the  personal  activity  and  earnestness  of  Pasteur  in 
these  human  experiments,  the  circumstance  that  the  rabic  virus  was  an 
invisible  foe  of  unknown  nature — all  these  features  combined  to  give  to 
these  studies  a  gi-eater  prominence  than  was  accorded  other  Pasteurian 


502  MEDICAL   EESEABCH  AND  EDUCATION 

investigations  of  equal  or  perhaps  even  greater  merit  from  the  stand- 
point of  originality  and  constructive  intellect. 

In  all  these  different  groups  of  researches  were  displayed  the  most 
active  powers  of  associative  thought  and  phantasy,  the  most  admirable 
capacity  for  self-criticism.  As  Pasteur  made  his  publications  in  a  terse, 
compact  style,  we  can  not  always  reconstruct  his  logical  processes  by 
reading  tliem.  His  methods  of  thought  and  procedure  were,  however, 
well  known  to  his  colleagues,  with  whom  he  loved  to  discuss  his  ideas 
and  plans  of  experiments.  They  found  him  spirited,  fertile  and  imagi- 
native in  his  conceptions,  frankly  communicative,  generous  in  giving 
help  and  wholly  absorbed  in  his  work.  Like  many  intensely  serious 
men,  Pasteur  lacked  somewhat  the  sense  of  humor.  His  feelings  of 
partisanship  were  so  strong  that  he  could  never  overcome  his  resentment 
toward  Germany,  and  he  permitted  this  to  color  even  his  relations  with 
German  scientific  workers.  Yet  one  should  dwell  but  lightly  on  these 
slight  imperfections  in  a  nature  of  such  great  gifts  and  such  lofty  and 
unselfish  purpose. 

At  the  time  when  Pasteur  was  beginning  his  research  on  anthrax,  a 
young  student  of  medicine  at  the  University  of  Strassburg,  Paul 
Ehrlich,  was  laying  the  foundations  for  that  uniquely  fertile  and  ver- 
satile career  of  medical  research  which  has  made  him  the  most  original 
and  picturesque  of  living  investigators  of  medical  science.  Although  at 
this  time  Ehrlich  was  especially  under  the  direction  of  the  anatomist, 
Waldeyer,  he  rapidly  developed  a  capacity  for  chemistry  which  was  a 
surprise  both  to  himself  and  to  the  chemist,  Adolf  von  Beyer,  whose 
lectures  had  been  systematically  cut  by  the  gifted  but  unconventional 
student.  For  unconventional  he  then  was  and  ever  has  been,  neglecting 
what  he  did  not  like  and  throwing  himself  with  fervor  and  intense 
energy  into  the  solution  of  the  themes  that  attracted  him.  From  the 
outset  it  was  clear  that  Ehrlich  would  make  a  career  as  an  experimental 
investigator.  Much  of  the  time  he  was  supposed  to  spend  in  taking  the 
usual  medical  courses  he  devoted  to  experiment.  When  Robert  Koch 
was  shown  through  the  laboratory  at  Breslau  by  one  of  the  professors 
his  attention  was  called  to  a  young  student  working  at  a  desk  covered 
with  bottles  of  dyestuffs.  "  There  is  our  little  Ehrlich,"  said  the  pro- 
fessor; "he  is  a  first-rate  stainer  of  tissues,  but  he  will  never  pass  his 
examinations."  The  prediction  about  the  examinations  came  perilously 
near  fulfilment :  Ehrlich  made  bad  flunks  and  it  is  hinted  that  he  would 


IMAGINATION   AND    IDEALISM  503 

never  have  received  his  degree  had  not  he  made  a  discovery — namely, 
the  existence  of  the  peculiar  type  of  leucocyte  which  is  known  to  us  as 
the  "  plasma-cell."  The  faculty  reasoned  that  it  would  be  improper  to 
keep  so  promising  and  original  a  worker  indefinitely  in  an  under- 
graduate position,  and  it  is  suspected  that  they  mitigated  the  rigor  of 
the  examinations  in  order  to  relieve  their  own  embarrassment. 

A  noteworthy  example  of  Ehrlich's  free-lance  method  is  seen  in  his 
peculiar  way  of  working  at  chemical  problems.  Though  a  highly  accom- 
plished organic  chemist,  both  as  to  theory  and  a  singularly  rich  acquaint- 
ance with  the  properties  of  substances,  Ehrlich  rarely  uses  any  but  the 
simplest  methods  and  quite  refuses  t9  work  quantitatively.  His  per- 
sonal experiments  are  almost  exclusively  test-tube  experiments,  most 
ingeniously  contrived  to  yield  a  rich  fund  of  knowledge.    He  says : 

For  the  pure  chemist,  who  proceeds  analytically  or  synthetically,  my  way  is 
only  an  unending  pons  asinorum.  The  chemist  starts  from  two  substances,  a  and 
ft,  both  of  which  he  knows,  and  by  synthesis  derives  substance  c.  Through  this 
procedure  a  sure  insight  into  the  nature  of  the  process  becomes  possible.  This 
is  exactly  as  if  one  drew  a  circle  with  the  calipers.  On  the  other  hand,  one  may 
define  a  circle  by  means  of  a  large  number  of  tangents,  and  the  chemistry  which 
I  practise  is  a  kind  of  tangent  chemistry.  Through  my  schooling  in  this  tangent 
chemistry  I  have  had  a  great  advantage  in  dealing  with  immunity  problems.  If 
one  cannot  define  chemically  the  components  entering  into  action,  as  is  frequently 
the  case  in  immunity  problems  (for  example  toxin  and  antitoxin)  one  cannot 
draw  the  circle  in  the  usual  chemical  way  and  the  nature  of  the  reaction  process 
must  remain  a  closed  book.  But  for  one  who  has  worked  for  decades,  as  I  have 
done,  at  tangent  chemistry,  the  task  is  no  longer  so  difficult ;  and  I  think  that 
in  this  way,  through  the  recognition  of  toxoids  and  their  quantitative  formation 
from  toxins,  I  have  succeeded  in  correctly  bringing  out  the  two  functional  groups, 
the  toxophore  and  the  haptophore,  which  indeed  furnish  us  with  the  key  to  the 
entire  doctrine  of  immunity. 

Ehrlich's  dominant  interests  during  the  student  davs  were  histology 
and  chemistry,  but  his  attitude  toward  these  subjects  was  even  then 
highly  individual,  original  and  laden  with  the  dynamic  spirit — the  spirit 
that  seeks  to  gain  a  conception  of  what  goes  on  in  the  living  cells. 
Throughout  his  career  Ehrlich  has  sought  to  use  his  knowledge  of  his- 
tology and  of  chemistry  to  gain  light  on  the  process  of  life.  The  clarity 
of  his  visual  perceptions  and  the  tenacity  of  his  visual  memories  have 
enabled  him  to  cultivate  a  sort  of  chemistry  peculiarly  suited  to  this  aim. 
Ehrlich  early  recognized  that  he  had  a  peculiar  gift  of  being  able  to 
recall  and  represent  mentally  the  constitution  of  a  large  variety  of  sub- 
stances and  with  little  effort  to  picture  vividly  their  interactions.     He 


504  MEDICAL   EESEAECE  AND  EDUCATION 

definitely  states  that  he  considers  this  chemicoplastic  memory  his  great- 
est scientific  endowment,  and  it  is  clear  that  the  long  line  of  his  inves- 
tigations is  founded  on  this  faculty  and  on  his  taste  for  rational  thera- 
peutics. Like  Helmholtz  and  Pasteur,  Ehrlich  has  been  guided  in  his 
experiments  by  certain  well-defined  general  conceptions.  The  most 
important  of  these  in  Ehrlich's  case  is  the  idea  that  the  living  cells  have 
many  different  kinds  of  definite  chemical  affinities,  by  virtue  of  which 
they  are  able  to  enter  into  combination  with  some  compounds  and  not 
with  others.  This  idea  is  at  the  foundation  of  Ehrlich's  well-known 
researches  on  the  basophilic,  acidophilic  and  neutrophilic  leucocytes,  on 
the  distribution  of  dyestuffs  in  the  so-called  "intravital"  staining,  on 
the  cell  affinities  of  the  different  alkaloids,  on  the  side-chain  theory  of 
immunity  and  the  measurement  of  the  strength  of  antitoxin,  and  on  the 
organic  chemical  compounds  of  arsenic  in  relation  to  the  trypanosomes 
of  the  sleeping-sickness. 

The  recital  of  Ehrlich's  achievements  in  medicine  would  demand  a 
voluminous  space,  for  his  activities  have  been  intense  and  varied.  The 
pharmacological  studies,  the  work  on  immunity  in  its  different  phases 
(including  the  action  of  hemolysins),  the  experimental  studies  on 
carcinoma — each  of  these  deserves  the  most  careful  study,  not  njerely 
because  of  actual  results  gleaned,  but  on  account  of  the  luminous 
ingenuity  of  the  methods  employed. 

It  is  in  the  field  of  immunity  that  Ehrlich  has  won  his  brightest 
laurels.  The  discovery  that  vegetable  poisons  like  abrin  and  ricin  excite 
antitoxicity,  the  development  of  a  method  of  measuring  the  activity  of 
the  diphtheria  antitoxin — a  standard  method  the  world  over — the 
extremely  ingenious  studies  of  hemolysins,  the  recognition  of  the  laws 
of  transmission  of  immunity  from  mother  to  child,  and  the  discovery  of 
immunity  in  trypanosomes  exposed  to  the  action  of  arsenical  poisons, 
are  all  contributions  of  far-reaching  import.  And  cementing  all  Ehr- 
lich's special  investigations  of  immunity,  relating  them  also  with  his 
work  on  the  distribution  of  dyestuffs,  alkaloids  and  nutritive  materials 
generally,  stands  the  famous  "  side-chain  "  theory.  This  bold,  elaborate 
and  refined  hypothesis  of  the  nature  of  immunit}^,  this  offspring  of  rich 
phantasy  and  fertile  experimentation,  M^as  long  the  source  of  discord 
and  strife  among  bacteriologists  and  pharmacological  theorists.  At  the 
height  of  the  controversy  Ehrlich  once  remarked :  "  They  are  shooting 
into   my   antitoxin   tower   and   I   will   reply   vigorously."     To-day   a 


IMAGINATION   AND    IDEALISM  505 

welcome  peace — perhaps  merely  a  truce — ^has  succeeded  the  sometimes 
heated  contest,  and  only  an  occasional  stray  shot  is  heard.  However 
widely  the  rival  camps  may  disagree  on  certain  points,  there  seems  now 
to  be  a  common  ground.  The  centrally  emergent  conception  in  immu- 
nity appears  to  be  the  existence  of  a  specific  binding  or  anchoring  avidity 
between  the  immunity-excitant  or  antigen  and  certain  substances  be- 
longing to  the  living  cell — the  so-called  receptors.  This  conception 
and  the  extensions  that  follow  from  it — including,  for  example,  the 
now  familiar  view  that  the  antitoxin  freed  in  the  blood  represents 
excessively  multiplied  receptors  disengaged  from  the  stimulated  cells — 
are  peculiarly  original  with  Ehrlich.  His  mind  reached  this  central 
idea,  because  it  is  a  mind  beset  by  chemical  phantasy,  a  mind  seeking 
to  explain  all  biological  phenomena  in  medicine  by  means  of  chemical 
principles.  In  the  special  case  of  the  side-chain  theory,  Ehrlich's 
intimate  knowledge  of  the  chemical  and  biological  properties  of  the 
dyestuffs  played  a  very  large  part,  and  it  should  be  noted  that  the 
theory  is  in  this  sense  a  hybrid,  that  it  originates  not  from  a  purely 
chemical  conception,  but  from  a  chemical  and  a  biological  idea.  Slowly 
that  theory  grew  to  its  present  full  proportions  and  its  somewhat  be- 
wildering intricacies  of  superstructure.  In  this  elaborate  form  there  is 
doubtless  much  in  the  hypothesis  that  can  be  criticized  if  we  turn  to  it  in 
the  hope  of  learning  the  absolute  truth  in  respect  to  immunity.  It  is 
perhaps  just  to  say  that  the  value  of  the  theory  lies  largely  in  the  fact 
that  it  expresses  relationships.  Time  and  experiment  will  doubtless 
mold  it  anew.  But  whatever  changes  in  form  it  may  suffer,  the  data 
collected  by  Ehrlich  and  correlated  by  him  will  long  remain  a  monument 
to  his  experimental  genius  and  creative  imagination.  And  the  fair- 
minded  critic  will  remember  the  great  practical  services  which  this 
theory  has  rendered  and  is  still  rendering  to  medicine,  in  enabling 
investigators  to  pursue  their  experiments  in  new  territories  of  research 
in  immunity  by  giving  them  points  of  attack  and  lines  of  advance.  It 
is  stated  by  Wassermann,  the  discoverer  of  the  serum  reaction  of 
syphilis,  that  he  could  never  have  worked  out  this  biological  reaction 
had  he  not  possessed  the  side-chain  hypothesis  as  a  guide.  It  seems 
clear,  too,  that  the  intelligent  use  of  this  hypothesis  is  destined  to  aid 
us  greatly  in  learning  something  of  the  seat  and  mode  of  action  of  many 
drugs  of  which  we  now  know  but  little.  And,  again,  there  are  unmis- 
takable signs  that  the  side-chain  conception  will  give  many  a  clue  to 
the  understanding  of  the  nutrition  of  cells. 


506  MEDICAL  BESEABCE  AND  EDUCATION 

Ehrlich's  mind  is  singularly  labile,  playful  and  restless.  It  passes 
quickly  and  casually  from  one  subject  to  another,  yet  without  the  least 
confusion.  It  is  always  on  the  alert,  ready  to  dally  with  a  new  fact  or 
a  new  idea,  in  the  hope  that  it  will  illumine  one  of  the  many  experi- 
mental interests  with  which  consciousness  ever  teems.  Ehrlich  reads 
medical  literature  rapaciously  but  selectively,  ignoring  all  but  the 
themes  in  which  he  has  a  special  interest,  as  one  reads  who  reads  for  his 
pleasure  and  not  for  duty's  sake.  This  unusual  method  is  extremely 
effective  and  gives  a  highly  serviceable  command  of  facts  likely  to  be 
helpful  in  extracting  from  Nature  new  facts  by  experiment.  Even 
during  holiday  seasons,  this  spirituelle,  penetrating  mind  knows  no  real 
rest,  for  the  time  is  beguiled  by  the  reading  of  detective  stories,  even 
second-rate  ones,  in  the  hope  of  finding  some  new  and  complicated 
situation,  for  which  an  ingenious  solution  can  be  invented. 

It  is  a  cheering  sign  of  the  times  that  the  cultivated  classes  are  begin- 
ning to  recognize  the  essential  role  of  imagination  in  the  progress  of  the 
biological  and  medical  sciences.  President  Eliot  remarks  that  the 
nineteenth  century  has  taught  us  that,  on  the  whole,  the  scientific 
imagination  is  quite  as  productive  for  human  service  as  the  literary  or 
poetic  imagination. 

The  imagination  of  Darwin  or  Pasteur,  for  example,  is  as  high  and  produc- 
tive a  form  of  imagination  as  that  of  Dante,  or  Goethe,  or  even  Shakespeare,  if 
we  regard  the  human  uses  which  result  from  the  exercise  of  imaginative  powers 
and  mean  by  human  uses  not  merely  meat  and  drink,  clothes  and  shelter,  but  also 
the  satisfaction  of  mental  and  spiritual  needs. 

The  history  of  medical  discovery  is  a  long  chain  of  imaginative 
experiences  whose  links  have  been  welded  and  fixed  by  passing  through 
the  fiery  ordeal  of  appeal  to  experimental  tests.  And  could  we  but  set 
forth,  in  fitting  language,  the  true  story  of  these  mental  experiences, 
with  all  their  vicissitudes  of  hope  and  despair,  success  and  failure,  we 
should  certainly  dispel  for  all  time  the  wide-spread  notion  that  medical 
research  is  a  dry  and  painful  task,  to  which  only  an  unimaginative  mind 
can  turn  with  satisfaction. 

There  is  a  phase  of  imaginative  thought  and  feeling  which  expresses 
itself  in  a  strong  desire  to  jDursue  ideal  ends,  even  at  the  cost  of  the 
ordinary  prizes  of  life,  wealth,  material  power  and  physical  comfort. 
This  idealism  has  been  a  very  pronounced  attribute  of  the  great  masters 
of  medicine.  In  a  noteworthy  degree  they  have  all  possessed  it  and 
some,  like  Helmholtz  and  Pasteur,  have  led  lives  of  unpretentious. 


IMAGINATION   AND    IDEALISM  507 

simple  self-sacrifice  in  admirable  harmony  with  the  illustrious  and 
superlative  service  they  have  rendered  mankind.  This  idealism,  while 
clearly  a  moral  trait  in  the  conventional  sense,  seems  to  be  the  offspring 
of  the  creative  intellectual  attitude  and  especially  of  an  absorption  in 
work,  which  leaves  the  mind  neither  time  nor  inclination  to  seek  the 
petty  advantages  for  which  most  men  at  some  time  in  their  lives  find 
themselves  struggling.  For  these  reasons,  indifference  to  vulgar  aims 
and  aloofness  from  commonplace  interests  are  apt  to  be  found  where 
there  is  preoccupation  in  productive  work  of  a  high  order,  whether  this 
be  concerned  with  science  or  not.  But  in  the  medical  sciences  the 
rewards  are  so  great,  in  the  sense  of  personal  satisfaction  from  superior 
achievement,  that  there  is  an  especial  and  peculiarly  potent  incentive  to 
repress  those  exaggerations  of  the  self-preservative  instinct  which  show 
so  insistently  in  the  selfish  conduct  of  commonplace  persons.  Yet  I 
do  not  think  that  it  can  be  claimed  that  the  motives  of  even  the  greatest 
masters  of  medicine  have  always  been  purely  altruistic.  In  the  days  of 
struggle  for  recognition,  during  early  manhood,  there  has  commonly 
been  evidence  of  mixed  motives  for  action  even  in  the  case  of  the 
noblest  men;  and  at  this  we  can  hardly  wonder.  Sometimes  the  spirit 
of  self-interest  has  been  given  too  free  a  rein.  When  Behring  patented 
the  diphtheria  antitoxin,  avowedly  with  the  intention  of  gaining  money 
for  further  research,  he  committed  himself  to  a  dubious  policy  and  one 
that  deprived  many  children  of  the  benefits  of  the  life-saving  discovery 
by  raising  the  cost  of  the  antitoxin  serum  to  a  prohibitive  level.  When 
Morton  found  that  sulphuric  ether  could  be  used  for  purposes  of  general 
anesthesia,  he  had  no  hesitancy  in  trying  to  secure  for  himself  a  patent 
for  his  method.  When  we  contrast  this  attitude  with  that  of  Helm- 
holtz,  who  gave  the  ophthalmoscope  to  medicine,  and  of  Pasteur,  who 
freely  gave  his  immensely  valuable  discoveries,  it  is  hardly  necessary 
to  comment  on  the  difference  in  spirit  that  animated  these  men. 

There  is  a  special  quality  pertaining  to  the  greatest  masters  of  medi- 
cine which  arrests  our  attention  when  we  survey  their  life  work.  This 
is  the  wonderful  variety  and  number  of  their  discoveries.  We  are 
struck  with  this  quality  of  productivity  in  the  works  of  Hunter,  Mal- 
pighi,  Johannes  Miiller,  Claude  Bernard,  Helmholtz,  Pasteur,  Koch  and 
Ehrlich.  In  some  instances  the  range  of  topics  is  relatively  narrow,  as 
in  the  case  of  Koch,  or  extraordinarily  wide,  as  in  the  case  of  Helmholtz, 
but  in  nearly  all  instances  the  great  masters  have  been  repeatedly  pro- 


508  MEDICAL  BESEAECH  AND  EDUCATION 

ductive,  and  this  varied  productivity  on  a  high  plane  is  an  unfailing 
mark  of  genius.  On  the  other  hand,  it  is  necessary  to  recognize  that 
very  important  discoveries  in  medicine  have  been  made  by  men  who 
once  in  their  lives,  and  once  only,  have  attained  a  high  level  of  achieve- 
ment. There  are  two  examples  of  this  singularity  in  discovery  which  I 
would  bring  particularly  to  your  notice — one  the  discovery  and  develop- 
ment of  the  antiseptic  method  by  Lister  and  the  discovery  of  general 
anesthesia  by  Morton. 

When  Lister  visited  Pasteur  in  1865  he  was  much  impressed  by  the 
attitude  of  the  great  master  in  regard  to  the  wide  part  played  by  micro- 
organisms in  fermentation  and  disease.  As  a  surgeon  he  had  a  deep 
interest  in  the  diseases  of  wounds,  and  the  idea  established  itself  in  his 
mind  that  such  diseases  might  be  due  to  a  kind  of  fermentation  which 
might  be  checked  or  prevented  by  the  use  of  antiseptics.  This  idea, 
worked  out  by  Lister  with  the  utmost  patience  and  superior  intelligence, 
gave  the  wonderfully  far-reaching  results  with  which  we  are  all  familiar. 
The  important  results  of  Lister's  methods  are  not  limited  to  the  surgical 
diseases  of  human  beings.  By  making  it  possible  to  experiment  on 
animals  in  wholly  new  ways,  these  methods  have  placed  in  the  hands 
of  the  physiologist  a  powerful  instrument  for  the  extension  of  medical 
and  biological  knowledge  along  most  significant  lines  of  progress.  We 
have,  therefore,  to  concede  that  Lister's  discovery  is  one  of  such  rich 
fertility  as  to  make  it  rank  among  the  great  discoveries  of  medicine. 
Yet  it  can  not  be  claimed  that  Lister  was  a  great  scientist.  In  training, 
in  originality,  in  versatility  and  in  imagination  he  is  far  from  being  the 
peer  of  the  great  masters  of  whom  we  have  spoken.  And  we  see  here, 
again,  that  the  practical  import  of  a  discovery  is  no  arbitrary  measure  of 
the  scientific  attainments  of  the  discoverer. 

Hardly  less  valuable  an  asset  of  practical  medicine  is  the  discovery 
of  general  anesthesia,  but  it  appears  that  the  qualities  of  mind  revealed 
by  Morton  belong  to  a  level  less  high  than  those  of  Lister.  Morton  was 
an  alert,  enterprising  young  dentist  in  Boston,  who,  while  educating 
himself  in  medicine,  successfully  practised  his  calling  and  invented  an 
improved  system  of  dental  plates.  The  use  of  this  system  required  the 
free  removal  of  carious  and  otherwise  diseased  teeth,  and  this  caused 
great  pain.  To  relieve  this  pain,  Morton  pertinaciously  sought  an 
efficient  anesthetic.  After  many  unsatisfactory  trials  with  different 
substances,  he  experimented  with  sulphuric  ether,  given  him  by  Jackson, 


IMAGINATION   AND    IDEALISM  509 

the  professor  of  chemistry  in  the  Harvard  Medical  School.  In  1846  he 
succeeded  in  demonstrating  the  efficacy  of  sulphuric  ether  as  a  general 
anesthetic  and  thus  gave  to  mankind  a  precious,  almost  unequaled  boon. 

This  great  discovery  can  not  be  reckoned  as  one  of  high  fertility, 
since,  aside  from  anesthesia,  it  has  not  opened  new  lines  of  thought  or 
practical  service.  Neither  can  it  be  said  to  have  sprung  from  a  scientific 
mind  of  exalted  qualities  and  attainments.  It  has  the  earmarks  of  a 
child  of  empiricism.  Morton's  scientific  knowledge  was  slight  and  his 
mind  had  a  strong  conmiercial  bent.  The  singularity  of  his  discovery, 
the  only  one  of  his  life,  points  neither  to  fertility  of  resource  nor  to  lofty 
imagination,  but  rather  to  the  fortunate  combination  of  conditions 
under  which  he  insistently  exercised  his  ingenuity. 

Having  told  you  something  of  the  qualities  distinguishing  the 
modern  masters  of  medicine,  I  now  ask  your  permission  to  speak  of  cer- 
tain aspects  of  these  qualities  as  they  seem  related  to  the  career  of  the 
thoughtful  student  of  medicine.  And  first  of  all  I  would  correct  in  your 
minds  any  impression  I  may  have  made  of  a  discouraging  nature. 
Having  drawn  our  examples  of  medical  advance  so  largely  from  the 
work  of  supremely  gifted  men,  workers  in  laboratories,  many  of  whom 
have  not  been  practitioners  of  medicine,  or  have  only  casually  practised, 
it  may  possibly  appear  that  you  are  confronted  with  the  paradox  that  an 
essential  condition  of  the  loftiest  success  in  medical  science  is  to 
abstain  from  the  practise  of  medicine.  There  is,  indeed,  a  measure  of 
truth  in  this,  for,  as  I  have  already  tried  to  show  you,  entire  absorption 
in  the  practical  problems  of  medicine  unfits  men  to  pursue  with  the 
highest  success  the  career  of  discovery.  In  this  there  is  naught  of  real 
discouragement,  but  only  a  sign  that  the  problems  of  disease,  as  we  meet 
them  by  the  bedside,  are  far  too  complex  to  permit  solution  there.  There 
was  a  time  when  all  medical  discovery  was  based  directly  on  observa- 
tion at  the  bedside.  Then,  with  the  growth  of  anatomy,  the  invention 
of  the  microscope  and  the  coming  of  the  twin  handmaids  of  medicine, 
physics  and  chemistry,  the  laboratories  sprang  into  existence.  Much 
there  was  that  could  be  discovered  only  by  laboratory  methods,  and  so 
it  happened  that  some  men  were  justified  in  working  at  medicine,  and 
able  to  become  masters  of  medicine,  though  they  scarcely  left  their 
laboratories.  But  I  would  have  you  note  well  that  we  have  now  entered 
on  a  time  when  the  clinics  and  the  laboratories  must  work  more  and 
more  closely  together,  aiding  each  other  at  every  step  to  bridge  the  wide 


510  MEDICAL  BESEABCH  AND  EDUCATION 

chasms  of  our  ignorance.  And  just  here  lies  one  of  the  greatest  oppor- 
tunities for  the  alert  student  of  medicine,  undergraduate  and  post- 
graduate, to  do  something  worth  while.  For  the  problems  are  so  many, 
so  varied  and  so  widely  graded  as  to  their  difficulties  that  for  almost 
every  earnest  student  there  is  at  hand  a  theme  suited  to  his  powers  and 
training. 

I  have  intimated  my  belief  that  the  powerful  and  controlled  imagi- 
nation is  generally  associated  with  a  strong  vein  of  idealism.  The 
explanation  is  not  remote ;  the  imagination  separates  the  wheat  from  the 
chaff  in  the  realm  of  ideals,  picturing  vividly  what  will  yield  enduring 
satisfaction.  In  persons  of  average  capacity  and  imagination,  idealism 
is  more  halting  because  the  perceptions  of  what  is  permanently  worth 
while  are  less  definite  and  carry  less  firm  conviction.  Hence  in  such 
persons  idealism  of  conduct  is  less  spontaneous  and  calls  for  conscious 
effort  to  sustain  it.  It  is,  indeed,  a  quality  which  may  be  deliberately 
cultivated  if  the  germ  exists  in  the  character. 

What  I  would  like  particularly  to  impress  on  your  minds  is  that 
without  idealism  of  purpose,  without  the  willingness  to  make  sacrifices 
of  material  comfort  and  much  that  the  world  overprizes,  the  career  of 
the  student  and  practitioner  of  medicine  is  almost  certain  to  be  pitifully 
limited  and  mediocre.  He  will  do  well  who  has  the  character  to  run 
his  course  in  a  strong  spirit  of  independence,  satisfied  during  the  long 
years  of  professional  preparation  with  the  slender  means  that  permit 
the  prolongation  of  some  phase  of  the  student  life  long  after  graduation 
from  the  medical  school.  There  is  no  surer  road  to  hopeless  mediocrity 
than  that  which  leads  the  young  physician  to  assume  an  active  practise 
before  he  is  ripe  for  it.  On  the  other  hand,  the  student  physician  who 
waits  patiently,  year  by  year,  to  strengthen  his  intellectual  grip  on  the 
processes  of  disease,  if  possible  under  the  guidance  of  some  master  of 
medicine,  is  laying  the  unshakable  foundations  of  a  telling  and  distin- 
guished career.  He  need  have  no  anxiety  as  to  the  future  either  on  the 
score  of  professional  recognition  or  the  ability  to  earn  a  sufficient  in- 
come. For  the  world  needs  and  must  ever  seek  the  serious,  well-trained, 
idealistic  physician  whose  first  thought  is  to  render  a  high  grade  of 
service.  The  superior  type  of  student  will  not  dread  the  long  years  of 
preparation  in  laboratory  and  clinic.  He  will  eagerly  seek  them  and 
will  count  it  the  greatest  privilege  of  his  life  to  be  able  to  utilize  and 
develop  his  powers.     The  fascinating  interest  of  his  problem  and  the 


IMAGINATION   AND    IDEALISM  511 

elevation  of  his  ideals  will  keep  him  buoyant  under  circumstances  of 
discouragement.  If  he  be  blest  with  a  fair  share  of  imagination  and 
idealism  he  will  never  falter  in  the  struggle  to  make  a  worthy  career,  for 
he  will  know  that  he  is  treading  in  the  footsteps  of  the  great  masters  of 
medical  science  and  that  in  doing  so  he  is  helping  to  assuage  human 
suffering,  perhaps  also  to  illuminate  some  of  the  dark  problems  in  the 
baffling  mystery  of  life.  And  in  this  consciousness  will  he  find  ample 
compensation  for  the  self-abnegation  which  such  a  career  must  neces- 
sarily exact  from  its  votaries. 


THE  MEDICAL  SCHOOL  OF  THE   FUTUEE^ 

By  the  late  Henry  P.  Bowditch,  M.D.,  LL.D.,  D.Sc, 
Formerly  Professor  of  Physiology  in  Harvard  University 

Among  the  intellectual  movements  that  have  characterized  the  cen- 
tury now  drawing  to  a  close,  there  is  perhaps  no  one  more  deserving  of 
careful  study  than  that  which  is  concerned  with  providing  education  for 
the  people  in  the  school,  the  academy  and  the  university.  The  impor- 
tance of  popular  education  became  apparent  in  proportion  as  political 
freedom  was  secured  for  the  people.  Thus  Viscount  Sherbrooke,  better 
known  as  the  Hon.  Robert  Lowe,  in  the  reform  debates  of  1866  and 
1867,  after  the  passage  of  a  bill  for  the  extension  of  the  suffrage,  uttered 
the  well-known  words:  "We  must  now  at  least  educate  our  masters." 
The  same  sentiment  has  also  more  recently  been  embodied  in  the  in- 
scription on  the  Boston  Public  Library,  "  The  Commonwealth  requires 
the  education  of  the  people  as  the  safeguard  of  order  and  liberty,"  and 
in  the  Presidential  Address  of  Dr.  J.  M.  Bodine^  at  the  meeting  of  the 
Association  of  American  Colleges  in  1897,  we  find  the  same  idea  thus 
expressed :  "  In  America  the  citizen  is  king.  The  king  must  be  edu- 
cated to  wield  aright  his  ballot  sceptre." 

For  many  years  educators  looked  upon  their  work  with  no  little  com- 
placency. The  educational  systems  of  the  various  civilized  countries 
were  supposed  to  be  well  adapted  to  the  ends  in  view,  and  educational 
exhibits  have  generally  been  regarded  as  important  features  of  interna- 
tional expositions.  But  within  the  memory  of  most  of  those  now  before 
me,  signs  of  serious  discontent  have  not  been  wanting.  Education  has 
not  always  been  found  to  furnish  the  required  safeguards  for  order  and 
liberty.  Highly  educated  men  have  often  been  found  singularly  lacking 
in  mental  balance.  Schools  for  the  inculcation  of  "common  sense" 
have  never  yet  been  established.  Even  the  great  development  of  psy- 
chology as  an  experimental  science,  which  has  occurred  chiefly  within 
the  last  twenty-five  years,  though  it  has  served  to  establish  many  laws 

*  Published  in  the  Transactions  of  the  Congress  of  American  Fhysicians  and 
Surgeons,  1900. 

^American  Practitioner  and  News,  June  26,  1897. 

512 


TEE   MEDICAL    SCHOOL    OF    THE   FUTUBE  513 

of  mental  action,  has  thus  far  failed  to  justify  the  hope  that  pedagogy 
may  find  in  psychology  a  foundation  for  the  erection  of  rational  sys- 
tems of  education.  Indeed,  we  have  recently  been  told  by  one  of  the 
ablest  expounders  of  this  science,  that  it  is  a  great  mistake  for  teachers  to 
"think  that  psychology,  being  the  science  of  the  mind's  laws,  is  some- 
thing for  which  they  can  deduce  definite  programs  and  schemes  and 
methods  for  immediate  school-room  use.  Psychology  is  a  science  and 
teaching  is  an  art.  A  science  only  lays  down  lines  within  which  the 
rules  of  the  art  must  fall,  laws  which  the  follower  of  the  art  must  not 
transgress;  but  what  particular  thing  he  shall  positively  do  within  those 
lines  is  left  exclusively  to  his  own  genius."  ^ 

Even  this  general  guidance  has  been  very  imperfectly  afforded,  for 
the  limits  set  by  the  science  of  psychology  to  the  art  of  teaching  have 
never  been  precisely  defined.  In  fact,  the  most  fundamental  question  of 
all,  namely,  the  relation  of  mental  to  physical  development,  has  not  yet 
been  settled,  though  much  material  for  its  study  has  been  collected.  It 
is  not,  therefore,  surprising  that  in  many  countries  teachers  have  made 
too  great  demands  upon  the  time  and  strength  of  growing  children. 

This  has  been  clearly  the  case  in  some  parts  of  Germany,  where 
school  boys  from  eight  to  fifteen  years  of  age  have  found  their  vital 
energy  so  far  exhausted  by  the  school  work  required  of  them  that  they 
have  lost  all  inclination  for  vigorous  athletic  amusements  so  naturally 
indulged  in  by  Anglo-Saxon  boys.  The  deterioration  of  the  race  as  a 
result  of  too  close  application  to  intellectual  pursuits,  to  the  neglect  of 
the  physique,  has  been  fortunately  obviated,  in  the  case  of  Germany,  by 
the  army  system,  which  takes  entire  possession  of  the  youth  before  it  is 
too  late,  and,  by  requiring  him  to  devote  three  years  to  the  education  of 
his  body,  turns  him  out,  at  the  end  of  that  period,  a  young  man  with 
mind  and  body  trained  to  a  high  degree  of  efficiency,  well  fitted  for  civil 
as  well  as  military  pursuits,  and  comparing  favorably  in  all  respects 
with  men  of  his  age  in  other  nations.  Looked  at  from  this  point  of  view, 
the  German  army  must  be  regarded  as  an  important  part  of  the  educa- 
tional system  of  the  country,  though  as  a  piece  of  educational  machinery 
its  workings  can  not  be  considered  economical.  In  fact,  the  absurdity 
of  depending  upon  the  army  to  remedy  the  defects  of  the  school  system 
has  long  since  been  forced  upon  the  attention  of  German  educators,  and 
the  difficulties  above  alluded  to  are  now  in  a  fair  way  to  be  removed. 

^  W.  James,  ' '  Talks  to  Teachers,  "p.  7. 
34 


514  MEDICAL  BESEABCH  AND  EDUCATION 

In  our  own  country  diflficulties  of  a  quite  different  kind  have  been 
met  with.  Here  the  great  danger  which  threatens  our  system  of  popu- 
lar education  arises  from  its  close  association  with  party  politics.  The 
office  of  a  school  committeeman  in  one  of  our  large  cities  has  been  well 
described  as  "  the  smallest  coin  in  which  politicians  pay  their  debts,"  and 
as  long  as  the  education  of  our  children  continues  to  be  entrusted  largely 
to  men  who  consider  their  position  on  a  school  board  as  the  lowest  step 
of  the  political  ladder,  there  is  small  hope  of  the  adoption  of  rational 
methods  of  education.  Moreover,  this  intimate  alliance  between  educa- 
tion and  politics  greatly  aids  the  efforts  of  persons,  more  zealous  than 
discreet,  to  direct  the  instruction  of  children  in  accordance  with  their 
own  special  views.  Thus  nearly  all  the  states  of  the  union  have  upon 
their  statute  books  laws  requiring  the  physiological  action  of  alcohol  to 
be  taught  to  children  in  all  grades  of  the  public  schools.  These  laws  vio- 
late the  first  principles  of  pedagogy,  inasmuch  as  the  physiological  action 
of  a  drug  can  not  possibly  be  understood  without  a  familiarity  with 
anatomy,  physiology  and  chemistry  which  school  children  can  not  be 
supposed  to  possess.  They  have  been  passed  at  the  bidding  of  total  ab- 
stinence associations,  sometimes  in  opposition  to  the  earnest  protests  of 
the  teachers  entrusted  with  their  execution.  How  these  excrescences 
upon  our  educational  system  may  be  best  removed,  and  the  work  of  in- 
struction placed  under  the  control  of  those  best  qualified  to  direct  it,  are 
questions  demanding  serious  consideration. 

I  have  mentioned  these  instances  in  which  great  educational  systems 
have  been  found  wanting  merely  for  the  sake  of  pointing  out  that  the 
critics  of  our  methods  of  medical  education,  who,  as  Professor  Exner* 
has  shown,  are  now  raising  their  voices  in  every  land,  do  but  give  a  spe- 
cial expression  to  a  widespread  feeling  that  our  educational  systems  are 
not  accomplishing  all  the  objects  for  which  they  have  been  devised,  and 
that  the  discontent  which  they  imply  is  but  a  healthy  dissatisfaction 
with  the  results  thus  far  accomplished.  May  the  time  be  far  distant 
when  those  in  charge  of  our  educational  interests  shall  rest  content  with 
what  they  have  achieved,  for  this  will  indicate  that  a  state  of  stagnation 
has  been  reached  similar  to  that  which  characterizes  the  institutions  of 
the  celestial  empire,  and  that  no  further  attempt  is  to  be  made  to  adapt 
our  methods  of  instruction  to  the  constantly  widening  domain  of  hu- 
man knowledge  and  experience. 

*  Wiener  Tclinische  WocTienschrift,  1900,  No.  3. 


THE   MEDICAL    SCHOOL    OF    THE   FUTURE  515 

It  may  perhaps  be  well  for  me  at  this  point  to  offer  a  few  words  in 
explanation  of  the  selection  of  such  a  well-worn  theme  as  medical  edu- 
cation as  the  subject  of  my  remarks  this  evening.  It  is  true  that  in  re- 
cent years  the  subject  has  been  a  favorite  one  with  those  who  have  been 
called  upon  to  address  medical  associations  or  classes  of  graduating  stu- 
dents, and  if,  in  spite  of  this  fact,  I  venture  to  add  another  address  to 
the  fast-growing  literature  of  the  subject,  my  justification  may  be  found 
in  the  following  reasons.  In  the  first  place,  it  must  be  borne  in  mind 
that  such  addresses  are  very  quickly  forgotten.  "  Were  it  not  so,"  as  Dr. 
Billings  has  remarked,  "it  would  be  a  hard  world  for  address-givers." 
In  the  second  place,  the  progress  of  medicine  at  the  present  time  is  so 
rapid  that  new  points  of  view  are  constantly  being  secured,  and  it  is, 
therefore,  not  at  all  impossible  that,  even  at  comparatively  short  inter- 
vals, new  and  valuable  suggestions  may  be  made,  with  regard  both  to 
subjects  to  be  taught  and  to  methods  to  be  employed  in  giving  the  in- 
struction. 

Lastly,  it  so  happens  that  during  the  academic  year  now  nearly  com- 
pleted the  faculty  of  the  Harvard  Medical  School  has  inaugurated  an 
entirely  new  plan  of  instruction  in  the  sciences  of  anatomy,  physiology 
and  pathology.  This  scheme,  though  still  in  the  experimental  stage,  em- 
bodies ideas  of  such  fundamental  importance  in  medical  education  that 
its  presentation  to  a  representative  body  of  the  medical  profession  seems 
to  me  to  be  peculiarly  appropriate. 

I  shall  therefore  ask  you  to  consider  with  me  this  evening  what 
lessons  the  faculty  of  a  modern  medical  school  may  draw  from  recent 
advances  in  medical  science  and  recent  experience  in  medical  education, 
or,  in  other  words,  on  what  lines  the  instruction  of  a  medical  school  of 
the  first  rank  is  likely,  in  the  immediate  future,  to  be  organized.  I  say 
in  the  immediate  future,  for  what  changes  are  in  store  for  us  in  the 
course  of  the  nest  few  decades  it  is  equally  impossible  to  foresee  and  use- 
less to  speculate. 

Relation-  of  Medical  Schools  to  Universities 

One  of  the  most  hopeful  signs  of  the  times  in  the  field  of  medical 
education  is  the  growing  tendency  of  the  better  schools  to  ally  them- 
selves to  universities,  and  of  universities  to  establish  medical  depart- 
ments. Of  the  great  advantages  to  medical  education  which  may  be  ex- 
pected from  this  union  it  is  unnecessary  for  me  to  speak,  for  they 


516  MEDICAL  BESEABCH  AND  EDUCATION 

formed  the  subject  of  a  thoughtful  discourse  delivered  by  the  last  presi- 
dent of  this  congress  at  Yale  University  in  1888.^  The  twelve  years  that 
have  elapsed  since  he  spoke  have  brought  accumulating  evidence  of  the 
soundness  of  his  views.  In  fact,  it  is  difficult  to  see  how  a  private  medi- 
cal school  of  the  joint  stock  company  type  can  ever,  in  the  future,  rise 
to  the  first  rank,  for  such  a  school  is  not  much  more  likely  to  attract  en- 
dowments than  a  cotton  mill  and  without  endowments  the  enormous  ex- 
penses of  a  modern  first-class  medical  school  can  not  possibly  be  met. 

Great  as  are  the  benefits  to  a  medical  school  of  thus  forming  a  de- 
partment of  a  great  university,  the  advantages  of  the  union  are  not 
wholly  on  one  side.  Beside  the  increase  of  prestige  secured  to  the  uni- 
versity by  the  broadening  of  its  functions,  the  establishment  of  a  medical 
school  as  part  of  the  university  organization  greatly  facilitates  the  in- 
struction of  those  students  who,  without  any  intention  of  becoming 
physicians,  seek  in  the  study  of  the  medical  sciences  a  means  of  general 
culture  and  mental  discipline. 

The  relations  between  the  governing  body  of  a  university  and  its 
medical  faculty  in  matters  of  administration  are  often  defined  by  cus- 
tom and  tradition  rather  than  by  statutory  provisions,  and  vary  consid- 
erably in  different  institutions.  In  general,  two  methods  of  government 
may  be  distinguished.  Either  the  initiative  is  left  with  the  teaching 
faculty,  the  governing  body  exercising  simply  a  veto  power,  or  the  gov- 
erning body  acts  directly  without  necessarily  asking  advice  from  the  fac- 
ulty or  its  members.  The  former  method  of  government  is  most  likely 
to  be  found  in  those  cases  in  which  a  well-established  medical  school  has 
allied  itself  to  a  university  for  the  sake  of  the  mutual  benefits  that  may 
ensue  from  the  union,  and  the  latter  method  in  those  cases  in  which  a 
university  has  completed  its  organization  by  the  creation  of  a  medical 
department.  Both  methods  have  certain  advantages  and  neither  is  with- 
out its  drawbacks.  In  all  cases  men  are  more  important  than  methods. 
On  the  one  hand,  the  collective  judgment  of  a  teaching  faculty  on  mat- 
ters relating  to  medical  education  is  likely  to  be  of  more  value  than  that 
of  a  governing  body  which  may  not,  and  generally  does  not,  include 
physicians  among  its  members.  On  the  other  hand,  personal  and  selfish 
considerations  are  perhaps  more  apt  to  sway  the  judgment  of  a  faculty 
than  that  of  a  body  of  trustees,  especially  when  the  question  is  that  of 
the  appointment  of  teachers.     That  this  is  not  a  serious  danger,  how- 

'  New  Englander  and  Yale  Beview,  September,  1888. 


TEE   MEDICAL    SCHOOL    OF    TEE   FUTURE  517 

ever,  the  experience  of  Germany  seems  clearly  to  show,  for  in  that  coun- 
try, as  Dr.  Fallow  has  recently  pointed  out,  the  faculty  "  has  more  power 
in  regard  to  appointments  and  the  general  policy  of  the  university"® 
than  with  us,  and  yet  we  find  there  the  custom  of  calling  professors  from 
one  university  to  another  fully  established — a  custom  which  must  be  re- 
garded as  one  of  the  strongest  influences  in  maintaining  a  high  stand- 
ard of  educational  efficiency.  On  the  whole,  therefore,  even  with  this 
possibility  of  error,  the  judgment  of  a  faculty  would  seem  to  be  the 
safer  guide,  and  there  are  probably  few  boards  of  trustees  who  would 
feel  themselves  justified  in  disregarding  it  altogether. 

The  above-mentioned  advantages  of  a  union  between  a  medical 
school  and  a  university  will  naturally  become  more  obvious  as  the  prob- 
lems of  medical  education  become  more  complex  and  the  methods  of  in- 
struction more  costly.  Hence  we  may  expect  in  the  near  future  to  find 
all  of  the  better  class  of  medical  schools  under  the  aegis  of  a  university 
and  we  may  reasonably  hope  that  this  change  will  be  associated  with  a 
diminution  of  the  total  number  of  medical  schools  now  so  greatly  in  ex- 
cess of  the  needs  of  the  country. 

The  union  of  a  medical  school  with  a  university  at  once  compels  the 
consideration  of  the  proper  relation  between  the  academic  department 
and  the  professional  school.  To  say  that  the  former  should  be  the  feeder 
of  the  latter  and  that  the  holding  of  an  A.B.  degree  should  be  the  con- 
dition of  admission  to  professional  studies  is  to  adopt  the  position  taken 
by  two  of  our  leading  medical  schools. 

The  A.B.  degree,  however,  since  the  introduction  of  the  elective  sys- 
tem, no  longer  stands  for  a  definite  amount  and  kind  of  training. 
Hence  the  Johns  Hopkins  Medical  School  demands  not  only  the  di- 
ploma, but  also  evidence  of  ability  to  read  French  and  German  and  lab- 
oratory training  in  physics,  chemistry  and  biology.  The  Harvard  Med- 
ical School  is  content  to  accept  the  A.B.  diploma  as  evidence  of  fitness  to 
pursue  professional  studies,  stipulating  only  that  the  holder  shall  pos- 
sess an  adequate  knowledge  of  inorganic  chemistry.  Whether  the  ex- 
ample set  by  these  schools  will  be  generally  followed  is  quite  doubtful. 
Without  undervaluing  the  importance  of  collegiate  training  as  a  prepa- 
ration for  a  professional  career,  it  may  perhaps  be  contended  that  a 
properly  conducted  admission  examination  is  a  better  test  of  fitness  to 

'  Presidential  address,  American  Society  of  Naturalists,  December,  1899, 
Science,  January  5,  1900. 


518  MEDICAL  BESEABCH  AND  EDUCATION 

pursue  the  study  of  medicine  than  the  possession  of  a  diploma  the  value 
of  which  varies  so  much  with  the  character  of  the  college  bestowing  it. 
Moreover  the  possibility  that  a  young  man  unable  to  afford  the  expense 
of  a  college  course  may  yet  by  private  study  prepare  himself  for  a  pro- 
fessional career  is  not  to  be  lost  sight  of.  Hence  the  Harvard  school 
provides  for  the  admission  by  a  special  vote  of  the  faculty  of  young  men, 
not  holders  of  an  A.B.  degree,  who  may  furnish  satisfactory  evidence 
that  they  have  obtained  an  equivalent  education  and  that  they  are  con- 
sequently able  to  profit  by  the  instruction  which  the  school  has  to  offer. 

The  recent  lengthening  of  the  course  of  study  from  three  years  to 
four  in  all  the  best  medical  schools  of  the  country  has  drawn  renewed 
attention  to  the  importance  of  enabling  the  student  who  takes  the  A.B. 
degree  as  a  preparation  for  medicine  to  so  far  shorten  the  sum  total  of 
the  time  devoted  to  his  education  that  he  may  be  able  to  enter  upon  the 
work  of  his  profession  at  an  age  not  in  excess  of  that  at  which  his  Euro- 
pean confreres  begin  their  career  as  practitioners.  A  few  years  ago  an 
examination  of  the  best  accessible  evidence  on  the  subject  led  to  the  con- 
clusion that  foreign  systems  of  university  education  enabled  students  of 
medicine  to  enter  upon  their  life  work  at  least  two  years  earlier  than  was 
possible  for  the  alumni  of  Harvard  College,  a  condition  dependent  upon 
the  fact  that  the  changes  in  the  academic  department  which  had  raised 
the  age  of  graduation  had  been  made  with  little  regard  to  the  interests 
of  the  professional  schools  and  chiefly  for  the  purpose  of  making  the 
undergraduate  department  as  complete  as  possible  in  itself.  In  other 
universities  a  similar  condition  existed,  though  probably  not  to  the  same 
degree  as  in  Harvard. 

That  the  American  medical  student,  seeking  the  best  possible  prep- 
aration for  his  profession,  is  seriously  handicapped  by  these  conditions, 
has  been  generally  recognized,  and  the  question  of  the  best  method  of 
meeting  the  difficulty  has  been  widely  discussed.  The  most  thorough 
treatment  of  the  case  consists  in  reducing  the  academic  course  to  three 
years.  Less  radical  methods  are  the  provision  in  the  academic  depart- 
ment of  courses  of  instruction  by  which  students  may  anticipate  a  part 
of  their  professional  work  and  the  permission  to  count  the  first  year  of 
a  professional  course  as  the  fourth  year  for  the  bachelor's  degree.  The 
first  and  most  radical  method  meets  with  strenuous  opposition  owing  to 
the  deeply  rooted  traditions  which  surround  the  four  years'  academic 
course  in  this  country,  while  the  other  plans  violate  what  in  some  col- 


TEE    MEDICAL    SCHOOL    OF    TEE    FUTUBE  519 

leges  seems  to  be  regarded  as  an  educational  axiom,  that  one  course  of 
study  should  not  count  toward  two  degrees.  It  is  interesting  to  notice 
that,  without  any  specific  legislation  to  this  end,  the  quiet  working  of 
the  elective  system  has  in  Harvard  College  practically  solved  the  prob-- 
lem  by  bringing  about  a  condition  in  which,  as  President  Eliot  says,"' 
"Any  young  man  of  fair  abilities  can  now  procure  the  degree  in  three 
years  without  hurry  or  overwork,  if  he  wishes  to  do  so  or  his  parents 
wish  to  have  him."  The  President  further  ventures  to  predict  that 
"  within  a  time  comparatively  short  the  majority  of  those  who  enter  the 
freshman  class  will  come  to  college  with  the  purpose  of  completing  the 
requirements  for  the  degree  in  three  years."  As  soon  as  a  three  years' 
residence  becomes  the  rule  rather  than  the  exception,  a  young  man 
spending  four  years  in  college  will  of  course  be  regarded  either  as  defi- 
cient in  mental  capacity  or  as  having  wasted  his  time. 

That  a  reduction  of  the  academic  course  to  three  years  is  an  ad- 
vantage to  students  looking  forward  to  a  professional  career  or  to 
further  study  in  a  graduate  school,  is  too  obvious  to  need  discussion,  but 
it  is  interesting  to  find  the  change  advocated  in  the  interest  of  the  under- 
graduates themselves.  Professor  Clement  L.  Smith,  for  nine  years  dean 
of  Harvard  College,  points  out*  that  there  is  a  large  and  influential  class 
of  college  men  who  get  into  the  habit  of  frittering  away  their  time 
simply  because  they  have  so  much  of  it  and  that  "for  them  and  for 
those  whom  they  influence — and  these  men  make  up  the  largest  part  of 
the  class  we  are  now  considering,  the  men  who  go  from  college  into  ac- 
tive life — the  reduction  of  the  course  would  be  a  distinct  gain."  Nor 
need  we  fear  (as  has  sometimes  been  urged)  that,  in  thus  reducing  the 
length  of  the  college  course,  we  shall  lose  the  fourth  and  most  valuable 
year,  for,  as  Professor  Smith  says,  "  The  senior  year  is  the  best  year, 
not  because  it  is  the  fourth,  but  because  it  is  the  last  year.  The  causes 
which  make  it  what  it  is  come  from  before,  not  from  behind;  from  the 
consciousness  of  opportunity  passing  away  and  of  the  serious  problems 
of  life  close  at  hand.  The  period  of  waste  lies  between  the  fresh  zeal  and 
good  resolutions  with  which  the  youth  begins  his  course  and  the  growing 
sense  of  responsibility  with  which  he  draws  near  its  close.  It  is  this 
intermediate  period  that  would  be  shortened  in  the  brief  course.    It  is 

"Annual  Eeports  of  the  President  and  Treasurer  of  Harvard  College,  1898- 
99,  p.  10. 

*  Clement  L.   Smith,  "The  American  College  in  the  Twentieth  Century," 
Atlantic  Monthly,  February,  1900. 


520  MEDICAL  BESEABCH  AND  EDUCATION 

not  the  senior  year  that  would  be  cut  off;  it  is  rather,  let  us  say,  the 
sophomore  year,  and  with  it  might  well  go  its  absurd  name."  It  thus  ap- 
pears that  the  claims  of  the  college  and  of  the  professional  school  upon 
the  time  of  the  student  are  in  a  fair  way  to  be  harmoniously  adjusted. 

The  Elective  System 

Let  us  now  consider  in  what  way  the  medical  school  of  the  immedi- 
ate future  is  likely  to  differ  from  that  of  the  present  time  with  regard 
to  the  subject-matter  of  instruction.  The  most  striking  phenomenon 
presenting  itself  to  the  educator  of  to-day  is  the  recent  enormous  widen- 
ing of  the  educational  horizon.  "The  immense  deepening  and  widen- 
ing of  human  knowledge  in  the  nineteenth  century  and  the  increasing 
sense  of  the  sanctity  of  the  individual's  gifts  and  will  power  "  ^  are  the 
fundamental  facts  which  underlie  the  development  of  the  elective  sys- 
tem, but  it  is  important  to  bear  in  mind  that,  as  Professor  Smith  ob- 
serves,^" this  development  has  been  "  due  not  so  much  to  the  increase  of 
knowledge — for  not  all  new  knowledge  is  straightway  fit  for  educational 
purposes — but  rather  to  the  conversion  of  new  fields  of  knowledge  to  the 
uses  of  education." 

A  discussion  of  the  elective  system  of  education  with  its  attendant 
advantages  and  dangers  would  require  far  more  time  than  I  have  at  my 
disposal,  and  I  must  content  myself  with  pointing  out  the  possibility 
that,  in  this  period  of  transition,  the  educational  pendulum  may  have 
swung  to  an  extreme  position  and  that  too  much  attention  has  been 
given  to  the  accidental  differences  of  pupils,  while  the  essential  similar- 
ity of  their  natures  has  been  lost  sight  of.  In  discussions  on  individual- 
ity as  a  basis  for  the  elective  system  one  sometimes  hears  the  statement 
(attributed  to  Leibnitz)  that  no  two  leaves  of  the  same  tree  are  alike. 
This  dissimilarity,  however,  does  not  prevent  them  from  all  elaborating 
the  same  sap,  and  it  is,  moreover,  always  associated  with  sufficient  essen- 
tial similarity  to  enable  any  one,  with  even  the  most  elementary  knowl- 
edge of  trees,  to  distinguish  the  leaves  of  an  oak  from  those  of  a  maple. 

While  admitting  that  some  of  the  extreme  positions  now  maintained 
by  the  advocates  of  the  elective  system  may  in  the  future  have  to  be 
abandoned,  no  one  can  doubt  the  wisdom  of  adapting  the  education  to 
the  powers  of  the  mind  to  be  educated  and  of  allowing,  in  the  case  of 

"  C.  W,  Eliot,  Atlantic  Monthly,  October,  1899,  p.  443. 
^"  C.  L.  Smith,  Atlantic  Monthly,  February,  1900,  p.  219. 


TEE   MEDICAL    SCHOOL    OF    THE   FUTURE  521 

advanced  students,  the  choice  of  the  individual  to  be  a  determining  fac- 
tor in  the  selection  of  studies.  Let  us,  therefore,  inquire  to  what  extent 
the  elective  system  may  properly  find  a  place  in  the  curriculum  of  our 
medical  schools.  That  it  forms  an  essential  feature  of  our  post-gradu- 
ate schools  of  medicine  scarcely  needs  to  he  mentioned,  for  these  schools 
have  been  organized  for  the  express  purpose  of  enabling  graduates  in 
medicine  to  select  such  subjects  for  study  as  may  seem  to  them  desirable 
and  to  acquire  more  advanced  knowledge  than  was  possible  in  the  under- 
graduate course.  Moreover,  in  some  of  our  larger  schools,  since  the  es- 
tablishment of  the  compulsory  four  years'  course,  a  portion  of  the  in- 
struction of  the  fourth  year  has  been  given  in  elective  courses  in  various 
specialties.  The  elective  system  in  medicine  is,  therefore,  not  altogether 
a  novelty,  and  the  question  now  before  us  is  whether  it  may  be  profitably 
extended  to  the  earlier  years  of  the  course. 

In  his  remarks  at  the  dinner  of  the  Harvard  Medical  Alumni  Asso- 
ciation in  1895,  President  Eliot  used  the  following  language:  "There 
ought  to  be  in  the  Harvard  Medical  School  an  extended  instruction  far 
beyond  the  limits  of  any  one  student's  capacity.  This  involves,  of 
course,  some  optional  or  elective  system  within  the  school  itself,  whereby 
the  individual  student  should  take  what  is,  for  him,  the  best  four  years' 
worth,  the  faculty  supplying  teaching  which  it  might  take  a  single 
student  eight,  twelve  or  twenty  years  to  pursue."" 

One  year  ago  last  December,  in  an  address  which  I  had  the  honor 
to  deliver  in  New  York  before  the  American  Society  of  iSraturalists,^^ 
I  gave  the  reasons  which  seemed  to  me  conclusive  in  favor  of  this  exten- 
sion of  the  elective  system,  and,  with  your  permission,  I  will  take  the 
liberty  of  presenting  as  briefly  as  possible  the  views  there  set  forth. 

In  the  first  place,  it  may  be  assumed  that  a  medical  school  of  the 
first  rank  should  be  an  institution  in  which  the  most  advanced  instruc- 
tion in  all  departments  of  medicine  can  be  obtained,  and  on  this  assump- 
tion it  is,  of  course,  impossible  to  arrange  a  course  of  study  that  every 
student  must  follow  in  all  its  details,  for,  in  the  time  which  may  prop- 
erly be  devoted  to  a  course  of  professional  study,  it  is  quite  impossible 
for  even  the  most  intelligent  students  to  assimilate  all  the  varied  infor- 
mation which  such  a  school  may  be  reasonably  expected  to  impart. 
It  seems,  therefore,  to  be  evident  that  in  arrangmg  a  course  of  med- 

"  Bulletin  Harvard  Medical  Alumni  Association,  No.  8,  p.  40. 
"  See  Science,  N.  S.,  Vol.  VIII.,  No.  209,  p.  921,  and  Boston  Medical  and 
Surgical  Journal,  December  29,  1898. 


522  MEDICAL  BESEABCH  AND  EDUCATION 

ical  study  a  distinction  must  be  made  between  those  subjects  which  it  is 
essential  that  every  student  should  know  and  those  subjects  which  it  is 
desirable  that  certain  students  should  know,  that  is,  between  those 
things  of  which  no  man  who  calls  himself  a  physician  can  afford  to  be 
ignorant  and  those  which  are  important  for  certain  physicians  but  not 
for  all;  in  other  words,  provision  must  be  made  both  for  required  and 
for  elective  studies.  The  task  of  drawing  the  line  between  the  essential 
and  the  desirable  in  medical  education  will  require  the  greatest  possible 
good  judgment  and  readiness  for  mutual  concession  on  the  part  of 
those  engaged  in  the  work,  but  there  is  no  reason  to  fear  that  the  diffi- 
culties will  be  found  insuperable  when  the  importance  of  the  change  has 
once  been  recognized. 

Any  one  who  is  familiar  with  the  existing  methods  of  medical 
instruction  is  aware  that  in  nearly  every  department  many  things  are 
taught  which  are  subsequently  found  to  be  of  use  to  only  a  fraction  of 
those  receiving  the  instruction.  Thus,  the  surgical  anatomy  of  hernia 
is  taught  to  men  who  will  subsequently  devote  themselves  to  dermatol- 
ogy, future  obstetricians  are  required  to  master  the  details  of  physiolog- 
ical optics,  and  the  microscopical  anatomy  of  muscles  forms  a  part  of 
the  instruction  of  men  destined  to  a  career  as  alienists.  Now  no  one 
can  doubt  the  propriety  of  including  instruction  on  all  these  subjects 
in  the  curriculum  of  a  medical  school,  but  it  may  be  fairly  questioned 
whether  every  student  should  be  forced  to  take  instruction  in  them  all. 

To  better  indicate  the  nature  of  the  reform  which  I  am  advocating, 
allow  me  to  describe  a  possible  arrangement  of  a  course  of  study  in  the 
department  of  physiology,  with  which  I  am  of  course  more  familiar 
than  with  any  other.  An  experienced  lecturer  will  probably  find  it 
possible  to  condense  into  a  course  of  about  forty  or  fifty  lectures  all  the 
most  important  facts  of  physiology  with  which  every  educated  physi- 
cian must  necessarily  be  familiar.  Attendance  upon  these  lectures, 
combined  with  suitable  courses  of  text-book  instruction  and  laboratory 
work,  would  suffice  to  guard  against  gross  ignorance  of  physiological 
principles.  In  addition  to  this  work,  all  of  which  should  be  required, 
short  courses,  of  not  more  than  eight  or  ten  lectures  each,  should  be 
provided,  giving  advanced  instruction  in  such  subjects  as  the  physiology 
of  the  special  senses,  cerebral  localization,  nerve-muscle  physiology,  the 
internal  secretion  of  glands,  the  physiology  of  the  heart,  circulation 
and  respiration,  the  digestive  secretions,  the  reproductive  organs,  etc. 


TEE   MEDICAL    SCHOOL    OF    THE   FUTURE  523 

These  courses  should  be  elective  in  the  sense  that  no  student  should  be 
required  to  t£lke  them  all.  Each  student  might,  however,  very  properly 
be  required  to  choose  a  certain  number  of  courses,  which  when  once 
chosen  become,  for  the  student  choosing  them,  required  courses  leading 
to  examinations.  There  is,  in  my  opinion,  no  doubt  that  an  arrange- 
ment of  instruction  similar  to  that  here  suggested  for  physiology  could 
be  advantageously  adopted  in  the  departments  of  anatomy,  histology, 
bacteriolog3%  medical  chemistry,  pathology,  surgery,  and  in  the  courses 
of  instruction  in  the  various  special  diseases,  such  as  dermatology, 
ophthalmology,  etc. 

In  the  existing  state  of  medical  education  the  introduction  of  the 
elective  system  in  some  form  or  other  seems  to  be  an  essential  condition 
to  any  further  important  advance,  for  the  curriculum  of  most  of  our 
schools  is  already  so  crowded  that  no  considerable  amount  of  instruc- 
tion can  possibly  be  added.  Various  arguments  may,  of  course,  be 
advanced  in  opposition  to  the  change.  It  may  perhaps  be  urged  that 
no  choice  of  studies  can  be  made  without  determining  to  some  extent 
the  direction  in  which  the  work  of  a  future  practitioner  is  to  be  special- 
ized, and  that  such  specialization  can  not  be  properly  and  safely  per- 
mitted until  the  student  has  completed  his  medical  studies.  To  this 
it  may  be  answered  that,  whatever  may  be  the  dangers  of  too  early 
specialization,  the  dangers  of  crowding  the  medical  course  with  instruc- 
tion of  which  many  students  do  not  feel  the  need,  and  of  thus  encour- 
aging perfunctory  and  superficial  work,  are  certainly  no  less  serious. 
It  is,  moreover,  a  matter  of  common  observation  among  teachers  in 
medical  schools  that  a  certain  number  of  students  very  early  make  up 
their  minds  either  that  they  will  become  surgeons,  obstetricians,  or 
specialists  of  some  sort,  or,  on  the  other  hand,  that  they  have  a  strong 
aversion  to  certain  branches  of  medicine  and  a  determination  never  to 
practise  them.  For  such  students  a  prescribed  curriculum  necessarily 
involves  great  loss  of  time  and  energy. 

If  it  be  said  that  under  this  system  the  medical  degree  will  cease  to 
have  the  definite  meaning  now  attached  to  it,  and  that  it  will  be  imposi- 
sible  to  tell  from  his  diploma  in  what  way  a  physician  has  been  edu- 
cated, it  may  be  replied  that,  though  the  degrees  of  A.B.,  A.M.,  Ph.D. 
and  S.D.  are  affected  with  exactly  this  same  uncertainty  of  significa- 
tion, their  value  seems  in  no  way  diminished  thereby.  As  long  as 
the  M.D.  degree  stands  for  a  definite  amount  of  serious  work  on  med- 


524  MEDICAL  BESEABCR  AND  EDUCATION 

ical  subjects,  we  may  be  reasonably  sure  that  those  who  hold  it  will  be 
safe  custodians  of  the  health  of  the  community  in  which  they  practise. 
If  it  be  urged  that  the  elective  system  in  medical  education  will 
lead  to  the  production  of  a  class  of  physicians  who,  owing  to  the  early 
specialization  of  their  work,  will  be  inclined  to  overrate  the  importance 
of  their  specialty  and  to  see  in  every  disease  an  opportunity  for  the 
display  of  their  special  skill,  it  may  be  pointed  out  that  this  result  is 
apt  to  be  due  not  so  much  to  early  as  to  imperfect  instruction  in  the 
work  of  a  specialist,  and  that  since  the  elective  system  tends  to  en- 
courage thoroughness  in  special  instruction,  the  evil  may  be  expected 
to  diminish  rather  than  to  increase. 

Methods  of  Instruction 

Having  thus  recognized  the  necessity  of  remodeling  our  conception 
of  the  subject-matter  to  be  taught,  and  noted  the  importance  of  distin- 
guishing between  the  essential  and  the  desirable  in  medical  education, 
we  must  next  consider  by  what  methods  the  needed  information  may  be 
best  imparted  and  the  necessary  training  secured.  There  is  perhaps  no 
way  in  which  modern  educational  methods  differ  more  from  those  of  an 
earlier  period  than  in  the  greater  prominence  given  to  object  lessons. 
Beginning  with  the  kindergarten,  the  child  is  trained  to  cultivate  his 
power  to  observe  accurately  and  to  manipulate  skilfully,  and  through 
his  school  and  college  life  prominence  is  given  to  the  objective  side  of 
education  to  an  extent  which  would  have  seemed  to  the  book-trained 
pedagogues  of  a  former  generation  but  ill  adapted  to  provide  the  well- 
stored  mind  which  it  was  thought  to  be  the  principal  object  of  educa- 
tion to  secure.  In  the  professional  schools  also  the  reaction  against 
purely  didactic  methods  has  been  strongly  felt.  Even  in  those  profes- 
sional pursuits  to  which  the  object  method  might  seem  at  first  sight 
least  applicable,  in  the  study  of  the  law,  the  so-called  "  case  method  " 
of  instruction  has  been  found  to  exert  a  vivifying  influence. 

In  medical  education  in  this  country  it  is  interesting  to  note  that 
in  the  very  beginning  the  instruction  was  more  objective  in  its  char- 
acter than  at  a  somewhat  later  period.  In  those  early  days  it  was  in 
the  office  of  his  preceptor  and  at  the  bedside,  as  his  actual  assistant, 
that  the  embryo  physician  was  initiated  into  the  mysteries  of  his  call- 
ing. Then  followed  a  period  when  it  was  clearly  perceived  that  the 
trained  mind  is  necessary  to  interpret  the  data  of  observation,  and  that 


THE    MEDICAL    SCHOOL    OF    THE   FUTUEE  525 

mental  training  is  essential  to  correct  observing.  Hence  schools  were 
established  to  provide  this  training  by  means  of  systematic  didactic 
lectures  covering  all  the  departments  of  medicine  and  usually  extend- 
ing over  not  more  than  four  months.  These  schools  were  intended  at ' 
first  merely  to  supplement  the  work  of  the  preceptors,  but  in  process  of 
time  the  relative  importance  of  these  two  educational  agencies  was 
reversed  and  the  work  of  the  preceptors  became  supplementary  to  that 
of  the  schools.  The  function  of  the  preceptors  finally  became  so  sub- 
ordinate that  their  names  no  longer  appeared  in  the  catalogues,  though 
this  did  not  always  indicate  that  they  had  ceased  to  afford  students 
opportunities  for  practical  clinical  work.^^ 

The  schools,  once  established,  grew  chiefly  by  an  increase  in  the 
length  and  number  of  the  lecture  courses  as  new  and  important  subjects 
forced  themselves  upon  the  attention  of  the  medical  profession.  Against 
this  undue  extension  of  purely  didactic  methods  of  instruction  a  reac- 
tion has  now  set  in,  and  during  the  last  ten  or  fifteen  years  loud  voices 
have  been  raised  in  advocacy  of  more  objective  methods  than  those  at 
present  in  use.  It  is  not,  however,  the  reinstatement  of  the  preceptor 
that  is  urged,  but  rather  the  greater  use  of  laboratory  methods  in  the 
strictly  scientific  departments  of  medical  instruction  and  their  applica- 
tion as  far  as  possible  at  the  bedside  of  the  patient.  A  fruitful  discus- 
sion of  the  relative  advantages  of  the  laboratory,  the  lecture  and  the 
text-book  as  methods  of  medical  education  can  not  be  undertaken  with- 
out a  recognition  of  the  fact  that  this  education  has  a  double  object. 
In  the  first  place,  the  faculties  of  the  student  are  to  be  so  trained  that 
he  may  observe  carefully,  reason  correctly,  study  effectively  and  judge 
wisely ;  in  other  words,  he  is  to  be  "  trained  for  power,"  to  use  Presi- 
dent Eliot's  phrase.  In  the  second  place,  there  must  be  imparted  to 
him  a  sufficiently  large  fraction  of  the  acquired  medical  knowledge  of 
the  time  to  make  him  a  safe  custodian  of  the  health  of  the  community. 
Which  of  these  two  objects  is  the  more  important  is  a  question  which' 
we  need  not  now  discuss,  but  even  if  we  grant  all  that  is  claimed  by  the 
advocates  of  training  for  power,  it  is  evident  that  the  constantly  in- 
creasing range  of  subjects  with  regard  to  which  an  educated  physician 
must  be  informed  will  greatly  reduce  the  time  which,  in  the  curriculum 
of  a  medical  school,  may  properly  be  devoted  to  courses  of  instruction 
not  intended  to  impart  direct  and  valuable  information.     In  fact, 

"  Henry  Hun,  Albany  Medical  Annals,  October,  1896. 


526  MEDICAL  EESEABCH  AND  EDUCATION 

"training  for  power"  should  be  largely  a  function  of  the  academic 
department  of  a  university,  and  when  undertaken  in  a  professional 
school  should  be  so  directed  as  to  impart  at  the  same  time  the  greatest 
possible  amount  of  useful  information. 

Let  us  now  consider  how  far  the  didactic  and  the  laboratory  meth- 
ods of  instruction  are  each  adapted  to  secure  these  two  objects  of 
medical  education.  For  the  purpose  of  training  for  power  no  one  can 
doubt  the  value  of  the  laboratory  method.  Contact  with  the  phe- 
nomena themselves  and  not  with  descriptions  of  them  has  a  stimulating 
efEect  upon  the  mind  of  a  student,  the  importance  of  which  it  is  diffi- 
cult to  exaggerate,  but  it  does  not  follow  from  this  that  the  lecture,  the 
recitation  and  the  text-book  are  worthless  as  methods  of  training.  It 
is  here  that  some  of  the  advocates  of  laboratory  methods  have  committed 
what  appears  to  me  a  serious  error,  such  as  is  too  apt  to  characterize  all 
reform  movements,  the  error,  namely,  of  assuming  that,  because  one 
proposition  is  true,  another  proposition,  not  logically  inconsistent  with 
it,  must  be  untrue.  "  These  gentlemen,"  as  Professor  HowelP*  has 
expressed  it,  "  having  become  possessed  of  the  golden  truth  that  the 
best  knowledge  is  that  which  comes  from  personal  experience,  seem 
disposed  to  deny  all  value  to  knowledge  communicated  from  the  experi- 
ence of  others."  "We  are  told,  for  instance,  by  Dr.  Burr^^  that  the 
didactic  lecture  "  dates  from  the  time  when  printing  was  unknown  and 
manuscripts  were  rare  and  almost  priceless  and  the  only  means  of  com- 
municating knowledge  was  by  word  of  mouth.  To-day  it  is  in  large 
part  an  anachronism,  because  the  time  devoted  to  it  could  be  put  to 
better  uses." 

In  his  able  address^^  at  the  Yale  University  Medical  Commence- 
ment, my  colleague.  Dr.  C.  S.  Minot,  expressed  himself  as  follows: 
"  The  very  best  that  can  be  said  of  a  lecture  or  a  book  is  that  it  describes 
well  the  knowledge  which  some  one  possesses.  There  is  no  knowledge 
in  books.  ...  A  book  or  a  lecture  can  serve  only  to  assist  a  man  to 
acquire  knowledge  with  lessened  loss  of  time.  Knowledge  lives  in  the 
laboratory ;  when  it  is  dead  we  bury  it  decently  in  a  book.  ...  A  lec- 
ture is  a  spoken  book."  I  venture  to  believe  that  Professor  Minot's 
students  will  hardly  agree  with  this  estimate  of  the  lifeless  character  of 
either  his  written  or  his  spoken  instruction. 

"  Howell,  The  Michigan  Alumnus,  January,  1900,  Vol.  VI.,  p.  143. 
^^Philadelphia  Medical  Journal,  October  21,  1899. 
^«  Minot,  Science,  July  7,  1899. 


THE    MEDICAL    SCHOOL    OF    THE   FUTURE  527 

In  place  of  these  rather  disparaging  views  of  the  importance  of  a 
didactic  lecture,  I  am  inclined  to  accept  Dr.  "Weir  Mitchell's"  opinion 
that  "  The  best  lecturing  does  not  so  much  think  for  you  as  invite  you 
to  think  along  suggested  lines  of  inquiry."  If,  as  has  been  claimed, 
"  the  passive  attitude  of  listening  does  not  demand  of  the  students  intel- 
ligent thought,"^^  the  fault  must  lie  with  the  lecturer  and  not  with  the 
method  of  instruction.  In  every  department  of  medicine  advanced 
instruction  necessarily  deals  with  subjects  which  lie  within  what  Foster 
has  called  the  "penumbra"  of  solid  scientific  acquisition  and  about 
which  conflicting  views  are  therefore  certain  to  be  held  It  is  in  in- 
viting thought  with  regard  to  the  evidence  on  which  these  views  rest 
that  the  experienced  lecturer  has  his  best  opportunity  to  train  the  minds 
of  his  hearers.  Other  opportunities  are  also  afforded  by  the  historical 
presentation  of  subjects  about  which  differences  of  opinion  no  longer 
exist,  for  there  are  few  things  more  instructive  than  to  follow  up  step  by 
step  the  lines  by  which  our  knowledge  has  advanced,  noting  the  marks 
which  distinguish  the  paths  which  have  been  trodden  successfully  from 
those  which  have  turned  out  to  be  "no  thoroughfare."  Even  better 
opportunities  for  mental  training  than  those  which  the  lecture-room 
presents  are  afforded  by  the  recitation,  for  here  the  minds  of  the  teacher 
and  the  pupil  are  brought  most  closely  into  contact,  the  pupil's  difficul- 
ties are  appreciated  by  the  instructor  and  the  point  of  view  of  the 
teacher  can  be  learned  by  the  pupil.  It  has  always  seemed  to  me  that 
no  higher  enjoyment  falls  to  the  lot  of  the  teacher  than  that  which  he 
experiences  when,  by  a  series  of  carefully  considered  questions,  he  leads 
his  pupil  onward  from  the  known  to  the  unknown  and  notes  the  gleam 
of  intelligence  which  illumines  his  countenance  as  a  subject,  previously 
obscure,  becomes  clear,  as  a  result  of  his  own  mental  operations  guided 
by  his  teacher's  skillful  questions.  It  thus  appears  that  no  monopoly 
of  opportunities  for  mental  training  can  be  claimed  for  the  laboratory 
method  of  instruction. 

We  must  next  inquire,  what  are  the  relative  advantages  of  the  labo- 
ratory and  didactic  methods  as  means  of  imparting  information  ?  Here 
we  at  once  perceive  that  a  great  deal  will  depend  upon  the  kind  of 
information  to  be  imparted.  Certain  subjects  are  much  better  adapted 
than  others  to  be  taught  in  the  laboratory.     The  student  of  anatomy, 

1^  University  Bulletin,  Vol.  III.,  p.  85,  Philadelphia,  December,  1898. 
"W.  B.  Cannon,  A.M.,  "The  Case  Method  of  Teaching  Systematic  Medi- 
cine," Boston  Medical  and  Surgical  Journal,  January  11,  1900. 


528  MEDICAL  EESEABCH  AND  EDUCATION 

for  instance,  can  secure  the  greater  part  of  the  information  which  he 
needs  bj  laboratory  methods,  that  is,  in  the  dissecting  room,  though  a 
short  course  of  lectures  in  descriptive  anatomy  in  which  an  experienced 
teacher  emphasizes  the  salient  features  of  the  subject  will  probably 
always  be  indispensable.  Physiology  and  pathology  (including  physi- 
ological chemistry,  pharmacology  and  bacteriology)  are  subjects  in 
which  laboratory  instruction  may  be  unquestionably  much  more  freely 
used  than  is  customary  at  the  present  time.  The  recent  experience  of 
the  Harvard  Medical  School,  in  which  the  laboratory  courses  in  these 
subjects  have  been  greatly  extended,  has  furnished  conclusive  evidence 
of  the  value  of  this  method  of  instruction  as  a  means  both  of  imparting 
information  and  of  stimulating  the  mind  of  the  student.  It  must  be 
remembered,  however,  that,  as  Dr.  Welch^^  has  said,  "  laboratory  meth- 
ods are  extremely  time-taking  and  are  not  adapted  to  teach  the  whole 
contents  of  any  of  the  medical  sciences.  It  is,  of  course,  hopeless  to 
attempt  to  demonstrate  practically  all  of  even  the  more  important  facts 
that  the  student  should  learn." 

Moreover,  observed  facts  are  often  apparently  inconsistent  with  each 
other.  Equally  competent  observers  difEer  in  their  interpretation  of 
them.  Yet,  because  the  last  word  of  science  has  not  been  spoken  on 
these  subjects,  it  would  be  a  mistake  to  exclude  them  from  the  medical 
curriculum.  The  student  should  rather  be  carefully  instructed  as  to 
researches  which  have  not  yet  yielded  definite  results.  The  most  prob- 
able way  of  reconciling  conflicting  observations  should  be  pointed  out, 
and  he  should  be  shown  in  what  direction  the  search  for  truth  can  be 
prosecuted  with  the  best  prospect  of  success.  He  will  then  be  able  to 
appreciate  the  value  of  new  observations  and  to  assign  to  their  true 
position  the  reported  discoveries  in  medical  science. 

Instruction  of  this  sort  can,  of  course,  be  given  only  by  an  experi- 
enced lecturer  who  has  mastered  the  subject  of  which  he  treats.  It  is 
in  this  kind  of  teaching  and  in  the  exposition  of  those  facts  and  prin- 
ciples which  can  not  properly  be  made  the  subject  of  laboratory  instruc- 
tion to  students,  that  the  didactic  lecture  of  the  future  will  probably 
find  its  principal  field  of  usefulness.  In  the  latter  direction,  however, 
the  field  is  more  restricted  than  might  at  first  sight  appear,  for  the 
amount  of  practical  work  that  can  be  successfully  performed  by  first 

""Higher  Medical  Education  and  the  Need  of  its  Endowment,"  The 
Medical  News,  July  28,  1894. 


TEE    MEDICAL    SCHOOL    OF    TEE   FUTURE  529 

and  second  year  students  in  a  physiological  or  in  a  pathological  labo- 
ratory is  surprisingly  large.  In  the  physiological  department  of  the 
Harvard  Medical  School,  for  instance,  during  the  current  academic 
year,  each  pair  of  students  in  a  class  of  one  hundred  and  eighty  has 
been  furnished  with  a  kymographion,  a  capillary  electrometer,  a  moist 
chamber,  an  induction  coil,  unpolarizable  electrodes,  etc.,  and  the  most 
important  experiments  of  nerve-muscle  physiology  have  been  success- 
fully repeated.  The  fundamental  experiments  in  the  physiology  of  the 
circulation,  respiration,  etc.,  are  to  be  performed  in  a  similar  manner. 
In  the  pathological  laboratory  the  students,  working  in  sections  of  ten, 
have  had  an  opportunity  of  producing  for  themselves  and  studying 
experimentally  the  most  important  pathological  degenerations.  They 
have  also  studied  in  the  same  way  the  principal  infectious  diseases. 
In  the  anatomical  department  also,  while  the  number  of  didactic  lec- 
tures has  been  diminished,  the  whole  class  has  had  largely  increased 
facilities  for  the  practical  study  of  bones  and  of  various  special  organs. 
Still,  after  making  due  allowance  for  the  legitimate  expansion  of 
laboratory  teaching,  it  is  probably  safe  to  say  that  a  systematic  course 
of  lectures  in  each  of  the  medical  sciences  will  never  be  found  to  be 
superfluous,  and  that  the  day  is  probably  far  distant  when  the  lectures 
will  be  merely  "  explanatory  of  the  experiments."-** 

We  have  thus  far  considered  the  relative  advantages  of  didactic  and 
laboratory  methods  in  teaching  the  medical  sciences,  but  the  agitation 
in  favor  of  more  objective  teaching  has  extended  also  to  the  clinical 
departments  of  medicine  and  the  organization  of  "  clinical  labora- 
tories," in  which  the  cases  of  hospital  patients  may  be  studied  by  the 
most  refined  methods  of  physiological  and  pathological  research,  is  a 
natural  outcome  of  this  agitation.  In  fact,  however,  so  far  as  instruc- 
tion is  actually  given  at  the  bedside,  clinical  medicine  has  always  been 
taught  by  means  of  object  lessons.  In  many  of  our  schools  this  instruc- 
tion has  been  supplemented  by  so-called  "  conferences,"  exercises  in 
which  a  student  reports  before  the  class  a  case  which  he  has  himself 
examined,  giving  diagnosis,  prognosis  and  treatment.  The  subject  is 
then  discussed  by  the  class  and  finally  by  the  instructors. 

Wherever  actual  cases  of  disease  are  thus  utilized  for  teaching  pur- 
poses the  instruction  is  always  likely  to  be  more  or  less  haphazard  and 
unsystematic,  for  the  diseases  studied  will  be  those  of  which  actual 

^"Porter,  Boston  Medical  and  Surgical  Journal,  December  29,  1898. 

35 


530  MEDICAL  BESEABCE  AND  EDUCATION 

cases  happen  to  be  available.  To  remedy  this  difficulty  it  has  been 
recently  proposed^^  to  substitute  the  study  of  hospital  records  of  cases 
for  the  examination  of  the  cases  themselves,  a  method  quite  analogous 
to  that  known  as  the  "case  method/'  which  has  long  been  used  with 
great  success  in  training  students  in  the  Harvard  Law  School.  It  will 
thus  be  possible  to  group  cases  so  that  they  will  throw  light  upon  each 
other  and,  though  the  student  will  miss  the  stimulus  of  contact  with  the 
actual  patient,  the  method  presents  so  many  distinct  advantages  that  it 
will  doubtless  commend  itself  to  many  teachers  of  clinical  medicine 
and  of  theory  and  practise. 

It  is  thus  evident  that  the  reaction  against  purely  didactic  methods 
of  instruction  is  well  under  way.  It  is  a  movement  to  be  heartily 
welcomed,  for  there  can  be  no  doubt  that  medical  students  have  been, 
and  still  are,  too  much  lectured,  but,  like  all  other  reforms,  it  should  be 
carefully  guided  lest  useful  as  well  as  useless  things  be  swept  away. 
It  should  be  borne  in  mind  that  it  is  quite  as  easy  to  abuse  the  labo- 
ratory as  the  didactic  method  of  instruction  and  that  in  all  schemes  of 
education  a  good  teacher  with  a  bad  method  is  more  efEective  than  a 
bad  teacher  with  a  good  method.  As  Professor  HowelP^  has  well 
remarked,  "  Courses  of  lectures  that  if  analyzed  would  be  found  to  be 
top-heavy  and  lop-sided  and  otherwise  possessed  of  an  instability  that 
should  have  ensured  failure,  have  been  saved  and  made  instruments  of 
great  value  by  the  mere  earnestness  of  the  teacher." 

Distribution  of  Woek 

The  next  question  which  I  shall  ask  you  to  consider  is  that  of  the 
proper  distribution  of  the  work  of  a  medical  student.  Thirty  years 
ago  no  such  question  seems  to  have  presented  itself  to  the  minds  of 
instructors  in  medicine.  The  medical  faculties  of  that  time  contented 
themselves  with  providing  each  year  courses  of  lectures  covering  all  the 
departments  of  medicine,  as  they  were  then  understood,  and  every 
student  was  expected  to  attend  as  many  of  the  lectures  as  he  saw  fit. 
Between  1870  and  1880  the  fact  that  there  is  a  natural  sequence  in 
medical  studies  became  generally  recognized  and  graded  courses  of 
instruction  were  established  in  the  principal  medical  schools  of  the 
country.    The  grading  was  not,  however^  carried  sufficiently  far.    Thus, 

"W.  B.  Cannon,  A.M.,  loc.  eit. 
"^  Howell,  loc.  cit.,  p.  144. 


TEE   MEDICAL    SCHOOL    OF    THE    FUTUBE  531 

instruction  in  both  anatomy  and  physiology  was  generally  given  simul- 
taneously through  the  whole  of  the  first  year,  though  the  knowledge  of 
structure  should  logically  precede  a  study  of  function. 

The  time  seems  now  to  have  come  for  taking  another  step  in 
grading  medical  instruction,  and  during  the  academic  year  now  draw- 
ing to  a  close  instruction  in  the  Harvard  Medical  School  has  been  given 
in  accordance  with  a  plan  of  which  the  guiding  principles  are  concen- 
tration of  work  and  sequence  of  subjects.  Thus  in  the  first  half  of  the 
first  year  the  students  devote  themselves  exclusively  to  the  study  of 
anatomy,  including  histology  and  embryology.  In  the  second  half-year 
they  are  occupied  with  physiology,  including  physiological  chemistry, 
while  in  the  first  half  of  the  second  year  pathology,  including  bacteri- 
ology, engages  their  attention.  It  is  perhaps  too  early  to  pass  a  final 
judgment  upon  the  value  of  the  method,  but  thus  far  both  teachers  and 
students  seem  to  regard  it  as  a  success.  The  result  seems  to  have  justi- 
fied the  opinion  of  its  advocates  that  the  work  of  the  student  would  be 
made  "  easier  by  concentrating  his  thoughts  upon  one  subject  instead 
of  dissipating  his  attention  upon  many  subjects."^^  Nor  have  its  oppo- 
nents found  any  justification  for  their  fears  that  the  average  brain 
would  become  fatigued  and  unreceptive  by  too  close  application  to  one 
subject,  for  the  sciences  of  anatomy,  physiology  and  pathology  "  are  not 
narrow,  hedged-in  areas,  but  rather  broad  and  diversified  domains  com- 
posed of  many  contiguous  fields,"^*  in  passing  from  one  to  another  of 
which  the  student  may  rest  his  mind  without  interrupting  the  con- 
tinuity of  effort  essential  to  effective  work. 

An  obvious  objection  to  this  method  of  concentrating  instruction  is 
the  large  amount  of  work  which  it  imposes  upon  the  instructors.  There 
is  no  doubt  that  the  labor  of  teaching  every  day  in  the  week  may  task 
the  powers  of  even  the  most  enthusiastic  instructor,  but  it  has  been 
found  that  the  laboratory  work,  which  has  occupied  from  two  to  three 
hours  every  forenoon,  has  been  conducted  with  much  less  fatigue  than 
was  anticipated.  In  fact,  students,  when  supplied  with  printed  direc- 
tions for  work  and  with  the  necessary  apparatus,  need  remarkably  little 
supervision.  In  the  physiological  laboratory  it  was  found  that  one 
instructor  could  readily  supervise  the  work  of  fifteen  pairs  of  students, 
and  the  experience  in  the  anatomical  and  pathological  departments  was 
of  a  similar  sort. 

=^  Minot,  loc.  cit.     Eeprint,  p.  22. 
**  Porter,  loc.  cit.    Eeprint,  p.  12. 


532  tee  medical  school  of  tee  futuee 

Examinations 

Closely  connected  with  the  questions  of  method  of  instruction  and 
of  distribution  of  work  is  the  subject  of  examinations.  With  regard 
to  these  tests  of  our  educational  methods,  opinions  vary  even  more 
widely  than  with  regard  to  the  methods  themselves.  There  is  only 
one  pointy  as  Professor  Exner  has  remarked,  on  which  teachers  are 
practically  united,  and  that  is  "  that  an  examination  is  a  necessary 
evil."  Every  examiner  knows  only  too  well  that  an  examination  is  but 
a  very  imperfect  test  of  knowledge,  but  few  are  ready  with  any  sugges- 
tion of  a  substitute.  Much  of  the  confusion  which  prevails  in  the 
discussion  of  this  subject  would  be  removed  if  the  objects  to  be  secured 
by  an  examination  were  more  clearly  apprehended.  Professor  Exner^' 
points  out  that  examinations  may  be  broadly  divided  into  two  classes, 
namely,  the  Control priifung,  to  test  the  faithfulness  with  which  the 
student  has  performed  his  daily  tasks,  and  the  Reifeprufung,  to  deter- 
mine the  amount  of  his  permanently  acquired  knowledge  of  medical 
subjects. 

The  examination  which,  at  the  end  of  the  year,  covers  the  whole 
ground  of  the  twelve  months'  instruction,  and  which  is  so  common  in 
our  schools,  belongs  to  neither  of  these  two  classes  and  is  really  a  con- 
cession to  a  very  natural  wish  of  the  students  to  get  the  examination 
"  out  of  the  way "  while  the  subject  is  still  fresh  in  their  minds. 
Having  little  justification  from  an  educational  point  of  view,  we  may 
hope  to  see  it  abandoned  when  the  extension  of  laboratory  methods 
provides  in  the  note-book  and  graphic  records  of  each  student  the 
evidence  of  his  daily  work  and  thus  either  renders  a  further  examina- 
tion unnecessary  or  prepares  the  way  for  a  final  test  of  his  fitness  to 
receive  his  diploma  of  M.D.  Whether  the  written  or  the  oral  exam- 
ination affords  the  better  method  of  applying  this  test  is  a  question 
about  which  opinions  vary.  The  fact  that  some  persons  can  write  more 
readily  than  they  can  talk,  while  others  can  talk  more  readily  than  they 
can  write,  seemsi  to  be  a  reason  for  providing  a  mixed  method  of  exam- 
ination in  which  each  individual  may  have  an  opportunity  of  appearing 

to  the  best  advantage. 

Conclusions 

If  the  views  here  presented  are  well  founded,  we  may  expect  that  a 
medical  school  of  the  first  rank  will  in  the  immediate  future  be  organ- 
ized and  administered  somewhat  as  follows: 

"  Exner,  loc.  cit.    Reprint,  p.  3. 


TEE    MEDICAL    SCHOOL    OF    THE    FUTURE  533 

1.  It  will  be  connected  with  a  university,  but  will  be  so  far  inde- 
pendent of  university  control  that  the  faculty  will  practically  decide  all 
questions  relating  to  methods  of  instruction  and  the  personnel  of  the 
teaching  body. 

2.  It  will  ofiEer  advanced  instruction  in  every  department  of  medi* 
cine  and  will  therefore  necessarily  adopt  an  elective  system  of  some  sort, 
since  the  amount  of  instruction  provided  will  be  far  more  than  any  one 
student  can  follow. 

3.  The  laboratory  method  -of  instruction  will  be  greatly  extended 
and  students  will  be  trained  to  get  their  knowledge,  as  far  as  possible, 
by  the  direct  study  of  nature,  but  the  didactic  lecture,  though  reduced 
in  importance,  will  not  be  displaced  from  its  position  as  an  educational 
agency. 

4.  The  work  of  the  students  will  probably  be  so  arranged  that  their 
attention  will  be  concentrated  upon  one  principal  subject  at  a  time  and 
these  subjects  will  follow  each  other  in  a  natural  order. 

5.  Examinations  will  be  so  conducted  as  to  afford  a  test  both  of  the 
faithfulness  with  which  a  student  performs  his  daily  work  and  of  his 
permanent  acquisition  of  medical  knowledge  fitting  him  to  practise  his 
profession. 

If  I  have  clothed  these  conclusions  in  the  language  of  prophecy,  it 
is  because  the  title  of  my  discourse  has  laid  this  necessity  upon  me. 
In  forecasting  the  immediate  future,  I  have  borne  in  mind  the  history 
of  the  immediate  past,  and  if  I  have  failed  to  read  aright  the  indica- 
tions of  the  lines  on  which  our  medical  schools  are  to  advance,  it  must 
be  remembered  that  the  development  of  a  biological  science  and  of  itsi 
dependent  arts  not  infrequently  takes  place  in  totally  unexpected 
directions,  thus  introducing  into  the  path  of  educational  progress  per- 
turbations which  may  well  defy  prediction. 


INDEX 


Antiquity  to  1800,  Efforts  of  Isolated    Herrick,   James   B.^   The   Educational 


Investigators,  Eichaed  M.  Peakce,  1 

Bacteriology,  Pasteur  and  the  Era  of, 
Eichaed  M.  Pearce,  33 

Baedeen,  C.  E.,  Medicine  and  Sociol- 
ogy, 408 

Barker,  Lewellts  P.,  Medicine  and 
the  Universities,  323;  Medical  Edu- 
cation in  the  United  States,  241 

BowDiTCH,  Henry  P.,  The  Medical 
School  of  the  Future,  512 

Cannon,  "W.  B.,  The  Career  of  the  In- 
vestigator, 295 

Chance  and  the  Prepared  Mind,  Eich- 
aed M.  Peaece,  89 

Clinical  Medicine,  The  Science  of,  S.  J, 
Meltzer,  428 

Councilman,  W.  T.,  Experiences  of  a 
Medical  Teacher,  305 

DODSON,  J.  M.,  Addition  of  a  Fifth 
Year  to  the  Medical  Curriculum,  395 

Donaldson,  Henry  H.,  Eesearch 
Foundations  and  their  Eelation  to 
Medicine,  474 


Function  of  Hospitals  and  the  Hos- 
pital Year,  388 

Herter,  Charles  A.,  Imagination  and 
Idealism  in  the  Medical  Sciences,  487 

Hospital,  Eelation  to  Medical  Educa- 
tion and  Eesearch,  William  H. 
Welch,  183 

Hospitals  and  the  Hospital  Year,  Edu- 
cational Function  of,  James  B.  Hee- 
EICK,  388 

Howell,  W.  H.,  The  Medical  School  as 
Part  of  the  University,  195 

Imagination  and  Idealism  in  the  Med- 
ical Sciences,  Chaeles  A.  Heeteb, 
487 

Interdependence  of  Medicine  and  the 
other  Sciences  of  Nature,  William 
H.  Welch,  143 

Investigator,  Career  of  the,  W.  B.  Can- 
non, 295 

Jackson,  C.  M.,  On  the  Improvement 
of  Medical  Teaching,  367 

Keen,  W.  W.,  Duties  and  Eesponsibili- 
ties  of  Trustees  of  Public  Medical 
Institutions,  457 


Education,    Medical,    The    Hospital    in 

Eelation    to,    William    H.    Welch, 

183;  Liberty  in,  Feanklin  P.  Mall,  Laboratories  for  the  Medical  Sciences, 

211;   Certain  Ideals  of,  Charles  S.  The    Development    of,    Eichaed    M. 

MiNOT,    279;    in   the   United   States,  Peaece,  16 

Lewellys  F.  Baekee,  323  Laboratory  Years,  Equipment  and  In- 
Educational  Function  of  Hospitals  and  struction  of  the,  E.  P.  Lyon,  375 

the   Hospital   Year,  James   B.   Her-  Liberty  in  Medical  Education,  Feank- 

EicK,  388  LIN  P.  Mall,  211 

EwiNG,    James,    The    Public    and    the  Lyon,  E.  P.,  Equipment  and  Instruc- 


Medical  Profession,  440 
Experimental     Method,     Eichaed     M. 
Peaece,  89 

Foundations,  Eesearch,  and  their  Eela- 
tion to  Medicine,  Heney  H.  Donald- 
son, 474 


tion  of  the  Laboratory  Years,  375 

Mall,  Feanklin  P.,  Liberty  in  Med- 
ical Education,  211 

Medical,  Eesearch  in  American  Univer- 
sities, Eichaed  M.  Peaece,  68;  Edu- 
cation and  Eesearch,  Hospital  in  Ee- 


535 


536 


INDEX 


lation  to,  William  H.  Welch,  183; 
School  as  Part  of  the  University,  W. 
H.  Howell,  195;  Education,  Liberty 
in,  Franklin  P.  Mall,  211;  Educa- 
tion, Certain  Ideals  of,  Chakles  S. 
MiNOT,  279;  Eesearch,  Theobald 
Smith,  319;  Education  in  the 
United  States,  Lewellys  F.  Barker, 
323;  Teacher,  Experiences  of  a,  W. 
T.  Councilman,  305;  Curriculum, 
Addition  of  a  Fifth  Year  to  the, 
John  M.  Dodson,  395;  Profession 
and  the  Public,  James  Ewing,  440; 
Institutions,  Eesponsibility  of  Trus- 
tees of,  W.  W.  Keen,  457;  Sciences, 
Imagination  and  Idealism  in,  C.  A. 
Herter,  487;  School  of  the  Future, 
Henry  P.  Bowditch,  512 

Medicine,  and  the  Other  Sciences  of 
Nature,  Interdependence  of,  Wil- 
liam H.  Welch,  163;  and  the 
Universities,  Lewellys  F.  Barker, 
323;  The  Outlook  in,  G.  N.  Stewart, 
339;  and  Sociology,  C.  E.  Bardeen, 
408;  Clinical,  the  Science  of,  S.  J, 
Meltzer,  428 

Meltzer,  S.  J.,  The  Science  of  Clinical 
Medicine,   428 

MiNOT,  Charles  S.,  Certain  Ideals  of 
Medical  Education,  279 

Ophuls,  W.,  Eelation  of  Eesearch  to 
Teaching  in  Medical  Schools,  422 

Outlook  in  Medicine,  G.  N.  Stewart, 
339 

Pasteur  and  the  Era  of  Bacteriology, 
EicHARD  M.  Pearce,  33 

Pearce,  Eichard  M.,  Eesearch  in  Medi- 
cine, 1 ;  The  Experimental  Method, 
89;  Chance  and  the  Prepared  Mind, 
121 

Present-day  Methods  and  Problems, 
Eichard  M.  Pearce,  48 

Public,  and  the  Medical  Profession, 
James  Ewing,  440;  Medical  Institu- 


tions, Duties  and  Eesponsibilities  of 
Trustees  of,  W.  W.  Keen,  457 

Eesearch,  in  Medicine,  Eichard  M. 
Pearce,  1 ;  Problems,  Methods  and 
Organization  of,  G.  N.  Stewart, 
350;  Eelation  to  Teaching  in  Med- 
ical Schools,  W.  Ophuls,  422; 
Foundations  and  their  Eelation  to 
Medicine,  Henry  H.  Donaldson,  474 

Science  of  Clinical  Medicine,  S.  J. 
Meltzer,  428 

Sciences,  Medical,  Imagination  and 
Idealism  in  the,  Charles  A.  Herter, 
487 

Smith,  Theobald,  Medical  Eesearch, 
319 

Sociology  and  Medicine,  C.  E.  Bar- 
deen, 408 

Stewart,  G.  N.,  The  Outlook  in  Medi- 
cine, 339;  Problems,  Methods  and 
Organization  of  Eesearch,  350 

Teacher,  Medical,  Experiences  of  a,  W. 
T.  Councilman,  305 

Teaching,  Medical,  On  the  Improve- 
ment of,  C.  M,  Jackson,  367;  Eela- 
tion to  Eesearch  in  Medical  Schools, 
W.  Ophuls,  422 

Trustees  of  Public  Medical  Institu- 
tions, Duties  and  Eesponsibilities  of, 
W.  W.  Keen,  457 

Universities,  Medicine  and  the,  Lewel- 
lys F.  Barker,  323 

University,  Medicine  and  the,  William 
H.  Welch,  165;  Medical  School  as 
Part  of  the,  W.  H.  Howell,  195 

Welch,  William  H.,  The  Interdepen- 
dence of  Medicine  and  the  other  Sci- 
ences of  Nature,  143;  Medicine  and 
the  University,  165;  The  Eelation  of 
the  Hospital  to  Medical  Education 
and  Eesearch,  183 


4 


c 


L  I  ^  .^  A  R  Y 
SCRIP  PS      INSTITUTION 

OF     OCEANOGRAPHY 

UNIVERSITY     OF    CALIFORNIA 

LA  JOLLA.  CALIFORNIA 


